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�► 0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CON ACT NAME <br /> T � <br /> E FACI TYDDRES S T PHO # ith AREA C D <br /> CITY A�' T TE 2 P C of TANKS I <br /> P at SITE \Q <br /> P APPLI ANT/BIL ING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> CA MAKING A DRESS r P IC T PHONE # WITH AREA CODE <br /> N <br /> G W <br /> ia — U4 <br /> T . CITY I TE I E1,�ICATION <br /> stallation, etc.) <br /> TOTAL <br /> A TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> C <br /> T # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> I (multiply W-Ey—fee for <br /> V each year applicable) XXXX XXXX XXXX XXXX XXXX $ <br /> E <br /> TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ <br /> S <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> E # 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) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minim/TANK) # TANK(s)__L_ X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/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 _ $78.00/hour (8 hours minim/FACILITY) _ $624.00 minim $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E 77 <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minim/TANK) TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minim $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minim $ <br /> N TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hrSAMPLING INSPECTION FEE _ $78.00/hr $ <br /> TOTAL DUE 2�J <br /> ..»F..QI;...AF..F..x.-USS.._(?II.L.X...._....._...._.......... __. _...».._...... _.......__ _...__.._.»__.........»�»_..».___........».__»._»»...._»._....__ ...»»_.».._»....._........._..»».......»». <br /> _.................._..................._..................................:.».......__..._...•:::::: :....�......__......._.._ _.__..........._........_......_............_......................_._..........................................................»............_...:..__..............................».»............... <br /> _._........._.........._..._..................._............................... .»._.........._...__....._...:.__..._..»......_. __......................._.__...... _... _........».r.:.:».....................»..».»...................»».....».........:.;........................................ <br /> _......._»....._......_.._...._............_............................_».»_...».__.....»........._....._.........»» ....»............_»......_..._.._...................»........__............».. .................................::::: ::-::::::_........._..._.......................................... <br /> ................................._....._..........._............s».............r...r..-»..«........»..............................................»..».........._.............................................._.......................................:r_...........:..............._».. .......;...:::::•:..........::e................. <br /> u._..»_.suE'E*.... <br /> ..ff........»��i� III ... ......L"tiC�c —r_.o t» r•�cbY;�..-�a�;«� r-»� B fv �....�...ca ... j A.�».»..� .._. ry u...Y....».......r_ _ � C�Iv�D <br /> Iia <br /> 3F <br /> ...._._...........«.................. ...............................................».....................................«.».........»— <br /> _......._.... ........««.....................»........:. .sr.::::::-:::::a- ::::: ^ Y:::::-sa:::::::::::::::::r.:::::::::r.::::::u:r..::r.::::::rlU <br /> IIi..._....._.........................................................................-..»»....»...........................r....................._......_..»_._-..»:::--:::-::::::-::...».....__................«............ ............».......I:..............»»........................................................_. <br /> ............... <br /> ...... <br /> ............_......................................._..._.............................._.__...................................................e.....................».........................................._..............».......................3.....»............;.;;...::..........................................».............».................................»..... <br /> ...... <br /> ........................ <br /> .... <br /> EH 23 046 (Revised 9/11/96) Page 11 <br />