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1" <br />Y t SAN JOAQUIN COUJWLIC HEALTH SERVICES - ENVIRONMENTAL HEAL VSION <br />' UNDER STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAM <br />FACILITY CONTACT NAME <br />I <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />T <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = S <br />E <br />FACILITY ADDRESS)SITE ��// <br />SITE PHONE # with AREA CODE <br />& <br />105- C&uAi C,[, u/3 VLV'z2 <br />1986 <br />A <br />CITYSTATE <br />-ie-72wS <br />1989 <br />ZIP CODE <br /># of TANKS <br />at SITE <br />P <br />XXXX <br />= S234.00 minimum <br />-06 <br />P <br />L <br />APPLICANT/BILLING NA�M�E/ <br />APPLICANT CONTACT NAME <br />A� <br />I <br />/� �/ �nl �TT�a. <br />/ �-®ld6 <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />N <br />3 � <br />6 3—� <br />Y <br />CITY <br />s7 <br />STATE <br />ZIPCODE <br />4o' <br />TYPE of APPLICATION / <br />(Closure, instattation, etc.) <br />to January 1,1991) <br />5170/TANK <br />(After <br />15 <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = S <br />TOTAL <br />ANNUAL FACILITY FEE (Prior to January <br />1, 1991) = 5100.00 <br />TEMPORARY CLOSURE (Plan Review & inspections) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) <br />XXXX <br />XXXX <br />= S234.00 minimum <br />5 <br />$ <br />A <br />C <br />5 <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (If <br />Applicable) <br />N <br />I <br />XXXX <br />XXXX <br />S <br />5 <br />V <br />E <br />TANK FEE = 550.00/TANK <br />(Prior <br />to January 1,1991) <br />5170/TANK <br />(After <br />January 1, 1991) <br />F <br /># Tanks = <br />(multiply # by fee for <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 1991 1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />I <br />/� <br />5 <br />A <br />C <br />each year applicable) XXXX XXXX <br />I <br />L <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />$ <br />I <br />T <br />STATE SURCHARGE = S56.00 each TANK <br />(Due every 5 <br />years) <br />See California H & S Code, <br />Section 25287 <br />Y <br /># Tanks x $56.00 <br />1988 through <br />1990 <br />1991 through 1996 <br />(Enter amount and year) <br />E <br />S <br />I <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & inspections) <br />TANK I.D. #(s) <br />R <br />P <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />El <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) <br />5234.00 minimum <br />S <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />(> S <br />= S624.00 minimum <br />5 <br />R <br />E <br />REPAlR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />P <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />S <br />I <br />R <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum <br />5 <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum <br />5 <br />N <br />I <br />TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />$ <br />S <br />C <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br />= S78.00/hr <br />5 <br />TOTAL DUE <br />EH 23 032 (REVISED 10-28-93) <br />