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SAN JOAQUIN COON BLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACI Y`LIT�YY gqSIIT�TE NAM n� FACILITY PONT :T 6 <br /> T <br /> E FACILIjY ADDRESSAte- SITE PHONE # wi�t�h AREA COD <br /> & q1-5// Lae-4:�� -T77— <br /> CITY ST T ZI # of TANKS on�j u5+d I se�v <br /> at SITE 3 r'e MW'j- <br /> P <br /> PAPPLI:MLING NAM 14 APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILIN D S APPLICANT PHON # WITH AREA E <br /> N Che a eiKe- 5-f C� r <br /> T CITY �^ STATE JZ� C TYPE of APPLICATION <br /> 16 ' (23-- �5 (Closure, Installation, tc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX S <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for / <br /> A each year applicable) 1� �� ` D S �` D � <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX l� 5V '�� ( 140 <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 a= � 1991 through 1996 'gl ca <br /> (Enter amount and year) 9' <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.DO/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = S78.00/hr $ <br /> Ni)�k TOTAL E <br /> S <br /> F®R OFFICE USE ONLY �i •�/j <br /> $ �) <br /> NX <br /> Wio06ieeee6io06io000oiee6ieeee6i&a»eaieeeeiiiazoeodiaoieeeeii&a eSodaiooaieeeioieeiieeiieeieiieeCieeeeiiee4iees eews aaiedeeiieea eeeiiee:ieeeeeiees xeeao 06 yes xwN <br /> s�aot s MM ua1C L 5 � l� tUW 9 WX g <br /> Is 5 <br /> 4i.......................... .................... ........................ .................................. .............................. .................................... ...........................................9i <br /> EH 23 032 (REVISED 3-1-941 Peae 11 <br />