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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace)I <br />UNDER 7ORAGE TANK PROGRAM - FEE WORKSHEET <br />0 <br />S <br />ACILITY SITE NAME <br />f ILITY CONTACT NAME <br />S <br />U <br />R <br />I <br />TANK I.D. X(s) <br />c <br />FACILITY A4aqSS <br />$234.00 minimun <br />SITE PHONE # with AREA CODE <br />= $234.00 minimus <br />8 <br />P) <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. x(s) <br />` Y <br />` <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />P <br />C <br />at SITE <br />I SAMPLING INSPECTION FEE <br />P APPLICANT/BILLING NAME <br />S <br />APPLICANT CONTACT NAME <br />L <br />I <br />APPLICANT PHONE # WITH AREA CODE <br />_ <br />C K4444YG ADDRESS <br />N <br />T CIT <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />1986 1987 1988 1989 1990 <br />1 ( <br />A <br />C <br />XXXX rca <br />S <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />I <br />V TANK FEE = S50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br />0 Tanks = <br />F (multiply x by fee for <br />1986 <br />1987 <br />1988 11989 11990 <br />1991 11992 11993 <br />1994 11995 ( 1996 <br />A each year applicable) <br />xxxX <br />xxXx <br />C <br />S <br />I TANK PENALTY FEES ASSESSED <br />I XXXX <br />xxxx <br />L <br />I <br />S <br />I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y x Tanks x 556.00 1988 through 1990 <br />1991 through 1996 <br />ter amount and year) <br />S <br />TOTAL <br />C <br />L <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace)I <br />TANK I.D. #(s) <br />0 <br />S <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />X TANK(s) X 5234.00 = <br />S <br />U <br />R <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. X(s) <br />El <br />TEMPORARY -CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimun <br />5 <br />= $234.00 minimus <br />S <br />P) <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. x(s) <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimun/FACILITY) <br />, <br />= S624.00 minimum <br />S <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) I <br />TANK I.D. x(s) <br />PTANK <br />A <br />LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />I TANK(s) X S234.00 = <br />S <br />I <br />R <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum <br />S <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimus <br />S <br />NI <br />I <br />TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I <br />S <br />S <br />1 <br />C <br />CONSULTATION FEE = S78.00/hr <br />I SAMPLING INSPECTION FEE <br />= S78.00/hr <br />S <br />=('" USE ONLY <br />..+EEPS # I COMPUTER # I LOC CODE DIST CODE AMOUNT RECEIVED I CHECK #/CASH <br />3 <br />:H 23 032 (REVISED 10-28-93) 3 <br />TOTAL DUE I S <br />RECEIVED 3Y I DATE RECEIVED <br />C <br />4 <br />