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SAN JOAQUIN COU . BLIC HEALTH SERVICES - ENVIRONMENTAL HEAL IVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />IEAIT <br />'� t <br />E <br />& <br />FACILITY ADDRESS <br />SITE PINE # with AREA CODE <br />7A <br />Aat <br />CITY <br />E5CAC�00 <br />STATE <br />C4 <br />ZIP CODE <br /># of TANKS <br />SITE <br />P <br />-1 <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />LLnpj I <br />C <br />A <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />N <br />T <br />CITY ' STATE ZIP CODE TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />1986 1987 1988 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />A <br />$ <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX XXXX <br />$ <br />I <br />V <br />TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks = 1986 1987 1988 1989 1990 <br />1991 1992 1993 1994 1995 1996 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED XXXX XXXX <br />$ <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California <br />H & S Code, Section 25287 <br />T <br />Y <br /># Tanks x $56.00 1986 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />f <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimuo/FACILITY) <br />= S234.00 minimus <br />$ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) <br />= S624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum <br />$ <br />R <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum <br />$ <br />FOR OFFICE USE ONLY <br />EH 23 032 (REVISED 3-1-93) Pace 11 <br />