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SAN JOAQUIN COUNTYPUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAM <br /> T <br /> K li lti-i1L.L� <br /> E FACT ITY ADOpE5S SITE PHONE R with AREA CODE <br /> g (4 - LfI7 —b Vi- . ` � <br /> CITY STATE ZIP CODER of TANKS <br /> A 1- et SITE <br /> P c-V- <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> C MAILING ADDRESS APPLICANT PHONE M WITH AREA CODE <br /> N 100 �' q��-3,2 i 1 S" <br /> T CITY ST/1TEZIP CODE TYPE of APPLICATION �i✓.SY!JC,L� <br /> 6A_ L (Closure, Installation, etc.) <br /> TOTAL <br /> 1966 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) XXXX XXX( S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> M Tanks 3 1986 1 1987 1988 1989 1990 1991 1992 1 1993 1 1994 1995 1996 <br /> F (multiply M by fee for 5 I1 O l O o s <br /> A each year applicable) S <br /> C <br /> I TANK PENALTY FEES ASSESSED )IXXX X10(X 5 <br /> L <br /> I STATE SURCHARGE • 256.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> T <br /> Y s Tanks x 256.00 1986 through 1990 1991 through 1996 <br /> (Enter annuit and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Piece) TANK I.D. R(s) <br /> L <br /> 0 CLOSURE FEE • 578.00/hour (3 hours minimuNTANK) S TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review R Inspections) TANK I.D. d(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • S78.00/hour (3 hours minim WFACILITY) • 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 6 Cors traction Inspections) TANK I.D. d(s) <br /> L <br /> AlaN PLAN CHECK FEE = S78.00/hour (8 hours minimsNFACILITY) = 5624.00 minimum f <br /> R REPAIR FEE (Workplan Review d Construction Inspections) TANK I.D. /(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimun/TANK) t TANX(s) _ X 5234.00 S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) • $234.00 minimus S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimm/FACILITY) = 5234.00 minimum 5 <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION • 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S o 517001 <br /> FOR OFFICE USE ONLY _ <br /> _ _fiM IAM,M M�IIyw�MW.1�1M A�AII�MMYA MMIMIMA��MIW,MAIT.M�M1�I�.IM,YIr1W 11�IMYIfmM�111�11M�YIW.IW WM�IWI M1WIt�1�M IM�=MW�I�f"M WY�I,TM <br /> asffi�,yc S�'8""` C�fY�R'"A L"�L"Z`liR "'�S'Y'L'�"' I�RCd}I/�f�22'1tEt`€CVE'�' 'Lil�"k"L /�d41I""' '1C�"LE"CCEb"�'i"""'w 't3XY`�"'f!R'�JEIi""w ■ <br /> wwwwwwrFwwswwrwwasawasNwawwwawwawmwwwmrwwawwNwrwwwmwAmw wrrwwswwwaw swwrww <br /> EH Z3 032 (REVISED 3-1-931 <br />