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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIV ICN <br /> UNDERGR TORAGE TANK PROGRAM - FEE WORKSHEET <br /> S fACi ITT SITE FACILITY CONTACT NAME <br /> I ,y <br /> T ItV <br /> E FACIL(Y AD KESS SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE 0 of TANKS <br /> A oZ 3/ at SITE <br /> P <br /> P APPLICAN T/BILG NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILAdADORESS APPLICANT PHCNE S WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 1986 1987 1988 1 1989 1990 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicabte) X100( XXXX S <br /> t <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> N Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply x by fee for C G <br /> C each year appticabte) 70 S �foT <br /> I TANK PENALTY FEES ASSESSED <br /> XXXX XXXX S P <br /> l <br /> t STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Cade, Section 25287 <br /> Y 9 Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) 1 <br /> s6 Isr. <br /> C PERMANENT CLOSURE (Removat or Authorized Closure-in-Ptace) TANK I.D. #(s) Q�p <br /> L <br /> 0 CLOSURE FEE s 578.00/hour (3 hours minimua/TANK) 9 TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. 5(s) <br /> R <br /> E TEMPORARY CLOSURE FEE a 578.00/hour (3 hours miniaLWFACILITY) = $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (plan Review & Construction Inspections) TANK I.D. !t(s) <br /> L 5i2Du 31�3 <br /> AN PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum TS <br /> .�s� <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. SCs) <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) 0 TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = SZ34.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minima/FACILITY) = SZ34.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CCNSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE CNLT <br /> s rcc?S C I�tE,MMz L'�C i.0 ' S L 1 2i Lhi ' f C /u� ' i Li c E "�7w? <br /> ' ICIUMM cI <br /> S <br /> ;..a.r�rr�r�.ria�s ai�s�i�.ai�ri�aw rww r ww�r wau�a�rir�rw ris■was sir sr�rss s�waw�r+�i�s'wrirs ar.ai.ai�ai.ri.sa a:waii inti <br /> ;IM{AiMMRMR MMRfAf.7��1�������:C�IKlMMf��a��1����7�7�1M�7���l�aR�Ar�l1�7�f�K�ifK�����l��fKl� <br /> EN 23 032 !REVISED 3-1.931 • � • <br />