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11 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />TANK I.D. #(s) <br />FACILITY CONTACT NAME <br />I <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) <br />_ $624.00 minimum <br />$ <br />T <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />P <br />A <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK)# <br />E <br />FACILITY ADDRESS <br />I <br />R <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />SITE PHONE # with AREA CODE <br />$ <br />& <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minim <br />$ <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />at SITE <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />N <br />T <br />CITY <br />STATE <br />ZIP CODE TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />A <br />C <br />TANK FEE = S50.00/TANK (Prior <br />to January 1,1991) <br />$170/TANK (After January 1, 1991) <br />T <br /># Tanks = <br />1986 <br />1987 1988 1989 1990 <br />1991 1992 1993 1994 1995 1996 <br />I <br />(multiply W -By -fee for <br />XXXX <br />XXXX XXXX XXXX XXXX <br />$ <br />V <br />E <br />each year applicable) <br />S <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX XXXX XXXX XXXX <br />$ <br />T <br />STATE SURCHARGE = $56.00 each TANK <br />(Due every 5 years) See California H & S Code, Section 25287 <br />E <br /># Tanks x $56.00 <br />1986 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />$ <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />S <br />CLOSURE FEE = $78.00/hour (3 hours <br />minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour <br />(3 hours minimum/FACILITY) $234.00 minimum <br />$ <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) <br />_ $624.00 minimum <br />$ <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />P <br />A <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK)# <br />TANK(s) X $234.00 = <br />$ <br />I <br />R <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />= $234.00 minim <br />$ <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minim <br />$ <br />N TRANSFER FEE = $20.00 <br />I <br />S <br />C CONSULTATION FEE = $78.00/hr <br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />SAMPLING INSPECTION FEE = $78.00/hr <br />TOTAL DUE <br />EH 23 046 (Revised 7/10/96) Page 11 <br />$ <br />$ <br />