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SAN JOAQUIN C OLXTY PUBLIC HEALTH SERVICES - ENVIROUNMAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME F W TY CONTACT NAME <br /> E FA ILITY ADDRESS SITE PHONE # with AREA CODE <br /> & 4111, ful ( s <br /> A CITY ��� T TE P CODE # of TA KS <br /> '?j(n{ at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CT NAM <br /> L %N <br /> I <br /> C MAILLUG ADDRESS PLICANT PHONE # WITH AR E <br /> T LILITYI�C A�(�T STA,T 2I CODE T L I CATION <br /> (r S'2' losure, nstallation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) =X5100.00 <br /> 1986 1987 1988 1989 1990 <br /> A XXXX XXXX XXXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX Xxxx xxxx $ <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1!!7j 1988 1989 1 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply i�fee for <br /> A each year app icable) )OM )0= )O= $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX S <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See CaLffornia H & S Cade, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s)=-Z- > <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minims/TANK) # TANK(s) X 5234.00 = E <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 $ <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) = 5624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours rinimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00 hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE $ <br /> _F9R:S? I _ <br /> ii =Mfg' E`O�'UT' LbZ`-Cb15 � •-b't T-REUIve " <br /> !n <br /> iN s i� <br /> EH 23 032 (REVISED 4-29-94) Page 11 <br />