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i �!!DNt SAN JOAQUIN COUNTALIC HEALTH SERVICES ENVIRONMENTAL UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET P INSTALLATION PLAN CHECK (Plan Review & Construction ons) ti TANK I.D. #(s) TOTAL 1986 1987 1988 1989 1990 A ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 AN CHECK FEE = S78.00/hour (8 hours minimWFACILIT22 = $624.00 minimum S A $ C T FACILITY PENALTY FEES ASSESSED (If Appticable) X)0(X X)XX $ I V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) E # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 F (multiply # by fee for A each year applicable) S C I TANK PENALTY FEES ASSESSED XXXX XXXX $ L I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 T Y # Tanks x $56.00 1986 through 1990 1991 through 1996 (Enter amount and year) $ C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK Y.D. #(s) L 0 CLOSURE FEE = S78.00/hoar (3 hours minimum/TANK) # TANK(s) X $234.00 = 5 S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = 578.00/hoar (3 hours minimum/FACILITY) = $234.00 minimus 5 P INSTALLATION PLAN CHECK (Plan Review & Construction ons) ti TANK I.D. #(s) L A AN CHECK FEE = S78.00/hour (8 hours minimWFACILIT22 = $624.00 minimum S R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S A I TANK RETROFIT REPAIR FEE = 578.00/hoar (3 hours min./FACILITY) = S234.00 minimum S R PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 8234.00 minimum S FOR OFFICE USE ONLY EH 23 032 (REVISED 3-1-931 Paae 11