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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UXDf 3UUD STORAGE TANK PROGR/UI - FEE WORKSHEET7 <br /> TY SITE NAME FACILITY CONTA NAME <br /> FACILITY ADDRESS — SITE PHONE # with AREA CODE <br /> /� Y /F . /YL� !1 S•f- - SYe -G 73 '— <br /> CITY <br /> s <br /> CITY c STATE ZIP CODE # of TANKS <br /> A J� '-lG /?ice �i't j`5 ZrJ/ at SITE 2 _. <br /> P <br /> P APPLICANT/BILLING NAME TT APPLICANT CONTACT NAME <br /> L 5—u4 <br /> 1 <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A s3Y� <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION Q ck <br /> Cly Z1-1S I (Closure, Installation, etA <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 g� <br /> C <br /> A <br /> DO l0V /UU $ ov ti <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX D 10 /Uv $ 3 O v <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = �- 1986 1987 1988 1989 1990 1991 1992 1993 1994 1945 1996 - <br /> F (multiply # by fee forq; <br /> A each year applicable) �(70 /O 00 Yu --' �_��_ I L <br /> I TANK PENALTY FEES ASSESSED XXXX XXXXw � w�V <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H S Code, Section 25287 <br /> T <br /> Y # Tanks__..�—x S56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> {4 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) 1 <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum $ (L( <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ OAC <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> ........................:::::— —_ ..�_ .-: -- ::-::_-::_.�� =.�......Wim._..____•_�—.=_.— __------ ...—.._.._ <br /> C PUTER # OC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> 5 <br /> v 3 Z3 s <br /> EH 23 032 (REVISED 11-1-92) < Page 11 <br />