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" • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SI FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> A I Poo\) at SITE 'C>-- ro �- <br /> P <br /> P APPLIICANT/BILLING NAME APPLICANT CONTACT NAME <br /> [ <br /> C MAILING ADDRESS APPLICANT PHONE 9 WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLI <br /> L0 -1-40LJ F Crr25j` 0+ Y� (Closure tatlati , etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Appticabte) XXXX XXXX S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 2 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (muttipty # by fee for <br /> A each year applicable) XXXX )0= <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX )O= S <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <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 $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/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 = S78.00/hour (8 hours minimm/FACILITY) = $624.00 minimum S q <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E, <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimxn/TANK) # TANK(s) X S234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE S /(�-7/CC 2 <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> S _ <br /> y <br /> _...._...:._......_ .___..... - - -- - - <br /> EH 23 032 (REVISED 10-28-93) <br />