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4-018-1997 3:©6PM FROt 1 P. 1
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONNMNTAL HEALTH ]DIVISION
<br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET
<br /> S FACILITY SITE NAME FACILITY CONTACT NAME
<br /> 1
<br /> E FACILITY ADDRESg SITE NONE with A CODE
<br /> CITY- S ATEIP CODE k of TANKS
<br /> A �C t1�` �. - �� at SI
<br /> P TE
<br /> P AP LING NAME
<br /> L ICANT CONTACT NAME c
<br /> C h�NG ADDRESS APPLICANT NONE # WITH A COD
<br /> T CITY STATE ZIP CDD TYPE of APPLICATION
<br /> (C(osure, Installation, etc.)
<br /> TOTAL
<br /> A TANK FEE L 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991)
<br /> C
<br /> T # Tanks - 1986 -1987 1988IM
<br /> 1992 1993 1994 1995 1996
<br /> I (mu(tiply W-57—fee for
<br /> Y each year applicable) XXXX XXXX xXXX S
<br /> E
<br /> TANK PENALTY FEES ASSESSED XXXX xxxx XXXX $
<br /> S
<br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California N & S Code, Section 25287
<br /> T
<br /> E # Tanks x $56.00 1986 through 1990 1991 through 1996
<br /> (Enter -8i6unt and year)
<br /> E
<br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Pace) TANK I.D. #(s)
<br /> L
<br /> 0 CLOSURE FEE = S78,00/hour (3 hours minimum/TANK) 0 TANK(s)
<br /> S x S234.00 = 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) 5234.00 minimum $
<br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s)
<br /> L
<br /> A
<br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) - $624-00 minimum S i
<br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.O. #(s)
<br /> E
<br /> P TANK LINING REPAIR FEE a $78 AO/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 , S
<br /> A
<br /> \
<br /> /] R TANK RETROFIT REPAIR FEE 578.00/hour (3 hours min./FACILITY) _ $234.00 minimum $1-9 �,
<br /> PIPING REPAIR FEE , $78.00/hour (3 hours miniMUM/FACILITY) = $234.00 minimum $
<br /> 141 TRANSFER FEE a $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S
<br /> I
<br /> S
<br /> C CONSULTATION FEE - S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $
<br /> TOTAL DUE V.
<br /> F ,QFFICE. US:E QFI1..X
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<br /> EH 23 046 (Revised 7/10/96) J Page 11
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