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..i <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br />I <br />FACI,TY SITE NAME <br />-5170/TANK (After January 1, 1991) <br />FACILITY CONTACT NAME <br />, <br />C <br />i <br />I <br />V <br />GZ <br />1986 1987 1988 11989 1990 <br />1991 1992 11993 11994 11995 1996 <br />T <br />E <br />FACILITY ADDRESS <br />S <br />SITE PHONE # with AR CCOE <br />TANK PENALTY FEES ASSESSED%XXX <br />X%XX XXXX I XXXX XXXX <br />S <br />S <br />I <br />C3TY�/,/� - <br />STATE <br />2IP CODE <br /># of TANKS <br />A <br />N <br />at SITE <br />P <br />P <br />AP CANT/BIL IN NAM <br />vrr <br />AP4 ICANT ONT NAM <br />or <br />C <br />MAILING ADDRESS <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) I <br />APPLICANT PHONE # WITH AR CODE <br />A <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minima /TANK) <br />S DZ6 <br />N <br />T <br />CITY <br />I STATE ZIP CODE TYPE of APPLICATION <br />TANK I.D. #(s) <br />lll'W S10 (Closure, Installation, etc.) <br />TOTAL <br />A <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />-5170/TANK (After January 1, 1991) <br />C <br />i <br />I <br />V <br />#Tanks = <br />(multiply�6y—fee for <br />each year applicable) <br />1986 1987 1988 11989 1990 <br />1991 1992 11993 11994 11995 1996 <br />XXXX xxxx I XXX% XXXX xxxx I <br />S <br />E <br />TANK PENALTY FEES ASSESSED%XXX <br />X%XX XXXX I XXXX XXXX <br />S <br />S <br />I <br />STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Lode, Section 25287 <br />T <br />E <br /># Tanks x $56.00 <br />(Enter amount and year) <br />1986 through 1990 <br />1991 through 1996 <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) I <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minima /TANK) <br /># TANK(s) X 5234.00 <br />5 <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) I <br />TANK I.D. #(s) <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I <br />$234.00 minimum <br />5 <br />P <br />INSTALLATION P�CHECK(Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />AN� <br />PLAN CHECK FEEhour (8 hours minimm/FACILITY) <br />_ %24.00 minimus <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimus/TANK) <br /># TANKCs) _ X $234.00 = <br />5 <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum <br />s <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimus <br />S <br />M <br />TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />S <br />I <br />S <br />C <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE= <br />578.00/hr <br />S <br />TOTAL WE /`(o Tr Vv <br />EH 23 046 (Revised 9/11/96) Page 11 <br />