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SAN JOAQUIN COL PUBLIC HEALTH SERVICES - ENVIRO$WWTAL IML DIVSION
<br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET
<br />S
<br />FACILIT'f SIT AME
<br />1986
<br />xxxx
<br />FACILITY CONTACT NAME
<br />1988
<br />1989
<br />1990
<br />PLAN CHECK FEE - $78.00/hour (8 hours minimum/FACILITY) _ &624.00 minirmin
<br />S
<br />FACILITY ADDRESS
<br />SITE PHONE N wit AREAQCODE
<br />xxxx
<br />S
<br />_
<br />A
<br />1
<br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) - $234.00 minimum
<br />a
<br />A
<br />—
<br />CIT
<br />STATE ZIPS E M of TANKS
<br />c�--�iy�'td �Ll��/•`° a t SITE
<br />P
<br />L
<br />AP'PL�ICA,NUB�ILLING NAME
<br />eT1 �-F� �N' Ys�`� (G�a r�G
<br />A/�P/P�L)ICANT CONT CT NAME
<br />11[ t yrryJ
<br />AL?
<br />MAILING DRESS ,✓
<br />ALS PHONE WITH AREA CODE
<br />a-1 `YG. —*!T
<br />Nd
<br />ddd J
<br />.5
<br />1
<br />CITY [
<br />ST TE ZIP CODE TYPE of APPLICATION
<br /><Sk (Closure, Installation, etc.)
<br />TOTAL
<br />ANNUAL FACILITY FEE (Prior
<br />to January 1, 1991) = 5100.00
<br />1986
<br />xxxx
<br />1987
<br />xxxx
<br />1988
<br />1989
<br />1990
<br />PLAN CHECK FEE - $78.00/hour (8 hours minimum/FACILITY) _ &624.00 minirmin
<br />S
<br />%
<br />FACILITY PENALTY FEES ASSESSED (If Applicable)
<br />xxxx
<br />xxxx
<br />S
<br />_
<br />A
<br />1
<br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) - $234.00 minimum
<br />S
<br />I TANK FEE = $50.00/TANK
<br />(Prior
<br />to January 1,1991)
<br />S
<br />5170/TANK
<br />(After
<br />January 1, 1991)
<br />N Tanks =
<br />(mu l t i p l y N by fee for
<br />k each year applicable)
<br />1986
<br />1987
<br />1988
<br />- --- --
<br />1989
<br />---
<br />1990
<br />-----
<br />1991
<br />----
<br />1992
<br />----
<br />1993
<br />---
<br />-k
<br />1994
<br />1995
<br />1996
<br />xxxx
<br />-
<br />xxxx
<br />s
<br />I TANK PENALTY FEES ASSESSED
<br />xxxx
<br />xxxx
<br />S
<br />L
<br />I STATE SURCHARGE - $56.00
<br />each TANK
<br />(Due every 5 years)
<br />See California H a S Code,
<br />Section 25287
<br />1 _—
<br />Y N Tanks x $56.00
<br />(Enter amount and year)
<br />—
<br />1988 through 1990
<br />- --
<br />1991 through 1996
<br />- -
<br />S
<br />C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place)
<br />L
<br />0 CLOSURE FEE = $78.00/hour (3 hours minimim/TANK)
<br />S
<br />IJ TEMPORARY CLOSURE (Plan Review & Inspections)
<br />R —
<br />E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/TANK)
<br />TANK I.D. N(s)
<br />M TANK(s)
<br />TANK I.D. N(s)
<br />N TANK(s)
<br />X &234.00 Is Z 11-70"
<br />X &234.00 = T&
<br />P
<br />INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections)
<br />TANK I.D. N(s)
<br />L
<br />AMOUNT RECEIVED CHECK N/CASH
<br />RECEIVED BY
<br />A
<br />N
<br />PLAN CHECK FEE - $78.00/hour (8 hours minimum/FACILITY) _ &624.00 minirmin
<br />S
<br />R
<br />REPAIR FEE (Workplan Review 8 Construction Inspections)
<br />TANK I.D. N(s)
<br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr
<br />AMOUNT RECEIVED CHECK N/CASH
<br />RECEIVED BY
<br />E
<br />}
<br />P
<br />TANK LINING REPAIR FEE - S78.00/hour (3 hours minimum/TANK)
<br />N TANK(s) X $234.00 =
<br />S
<br />_
<br />A
<br />1
<br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) - $234.00 minimum
<br />S
<br />R
<br />PIPING REPAIR FEE - S78.00/hour (3 hours minimum/FACILITY) $234.00 minimum
<br />&
<br />H
<br />TRANSFER FEE 520.00
<br />LOC COOE
<br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr
<br />AMOUNT RECEIVED CHECK N/CASH
<br />RECEIVED BY
<br />&
<br />}
<br />S -
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<br />:
<br />C
<br />CONSULTATION FEE - &78.00/hr
<br />..........L... 1.1.!........L!.!
<br />.�;,; .• i;;;;;•;: ..
<br />SAMPLING INSPECTION FEE _ &78.00/hr
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<br />S
<br />TOTAL DUE
<br />S / % �'� 1►f00
<br />N OFFICE LISE ONLY
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<br />:,_..:u::!:as ....•.............................:.....
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<br />S1IEEPS N
<br />COHPUTER N
<br />LOC COOE
<br />DIST CODE
<br />AMOUNT RECEIVED CHECK N/CASH
<br />RECEIVED BY
<br />DATE RECEIVED ';
<br />}
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<br />EH 23 032 (REVISED 6-21-93) Page 11
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