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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIR0NMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />A. <br />I <br />FACILITY SITE NAME <br />7AV1 Is M(Nt mP <br />FACILITY CONTACT NAME <br />TSITE <br />E <br />FACILITY ADDRESS <br />33oo w'EST iA06 <br />PHONE # with AREA CODE <br />o Z <br />KSTATE <br />A <br />CITY <D_TOci<-t'o!j <br />CA- <br />ZIP CODE # of TANKS <br />I at SITE 3 <br />P <br />L <br />APPLICANT/BILLING NAME <br />/uflQ )Mc(LRAZ}( <br />APPLICANT CONTACT NAME <br />miKE LEE �i(b,3i3-I(b8 <br />1990 1991 1 1992 11993 1 1994 1 <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />NOS- NAVY DfjVF <br />T <br />C—ITYSTATE1 <br />'S_r,=,Cic.7rV1 <br />6f} <br />ZIP CODE <br />I RSz.o <br />TYPE of APPLICATION GC.0$L/2i~ <br />I (Closure, Installation, etc.) <br />A <br />TANK FEE 550.00/TANK <br />(Prior <br />to January 1,1991) <br />5170/TANK (After January <br />1, 1991) <br />C <br />T <br /># Tanks = <br />TANK I.D. #(s) <br />1986 1 <br />1987 <br />1 1988 <br />1 1989 <br />1990 1991 1 1992 11993 1 1994 1 <br />1995 ( 1996 <br />I <br />(multiply T-5y—fee for <br />S <br />V <br />each year applicable) <br />XXXX I <br />XXXX <br />XXXX <br />XXXX <br />XXXX I <br />E <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />I XXXX <br />XXXX <br />S <br />S <br />I <br />STATE SURCHARGE = 556.00 <br />each TANK <br />(Due <br />every 5 <br />years) <br />See California H & S Code, Section <br />25287 <br />T <br />E <br /># Tanks x $56.00 <br />1986 <br />through <br />1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure- in -Place) I <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minim/TANK) I <br /># TANK(s)_ X 5234.00 = S p 2„ -- <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minim/FACILITY) <br />5234.00 minim S <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)+ TANK I.O. #(s) <br />L <br />A <br />N PLAN CHECK FEE = 578.00/hour (8 hours minim/FACILITY) = 5624.00 minimum 5 <br />Rf <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) ( <br /># TANK(s) X 5234.00 = S <br />A <br />11 <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 minim S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minim/FACILITY) <br />= S234.00 minimum 5 <br />M <br />I) TRANSFER FEE = 520.00 <br />S <br />C1 CONSULTATION FEE = 578.00/hr <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br />SAMPLING INSPECTION FEE = 578.00/hr S <br />TOTAL DUE 1 -7O7, • —cT- <br />EH 23 046 (Revised 7/10/96) Page 11 <br />