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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION -360 <br /> UNDERGACUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> S FACILITY SITE NAME ACILITY CONTACT NAME <br /> I Castle Rock Forest Fir]LA <br /> T SITE PHONE ! with th AREA [ODE <br /> E FACILITY ADDRESS <br /> 34580 Corral Hollow Ro510) 447-0395 <br /> CITY 3 of TANKSA Tracy 6 •t SITE one <br /> vP APPLICANT/BILLING NAME APPLICANT CONTACT NAMEalifornia De artment Fred JacobsC MAILING ADDRESS APPLI CAMS PHONE / WI7N AREA CODE <br /> A P .O. Box 1034 707 576-2275 <br /> NE TYPE of APPLICATION <br /> T CITYTrac 6 (Closure, Installation, ete.)closure <br /> TOTAL <br /> 1966 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 $ <br /> A <br /> C $ <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) XXXX X%%)I <br /> I <br /> V TANK FEE • S50.00/1ANK (Prior to January 1,1991) $1 )TANK (After January 1, 1991) <br /> E <br /> t Tanks a 1986 1987 1988 1989 1990 1991 1992 1993 1991 1995 1996 <br /> F (m (tiply W-137-fee for $ <br /> A each year applicable) <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H B S Code, Section 25287 <br /> T <br /> Y a Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter Wn t and year) It <br /> C PERMANENT CLOSURE (Removal or Authorized C(caure-In-Plaes) TANK t.D. !(a) <br /> L <br /> 0 CLOSURE FEE • $78.00/hour (3 hours minlrmm/TANK) 3 tANK(s) I X $234.00 $ 1 3A OO <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. fU) <br /> R <br /> E TEMPORARY CLOSURE FEE • 378.00/h Dur (3 hours minla¢m/FACILITY) • $234.00 minimus f <br /> P INSTALLATION PLAN CHECK (Plan Review L Construction Inspections) TANK I.D. /(t) <br /> L <br /> N PLAN CHECK FEE • 378.00/hour (8 hours IhlnlaudFACILITT) $624.00 mini" t <br /> R REPAIR FEE (Workplan Review B Coretruetian Irrpectlona) TANK I.D. 3(a) <br /> E <br /> P TANK LINING REPAIR FEE • S78.00/hour (3 hours minlaur,/TANK) S TANK(s) IT $234.00 • It <br /> A <br /> I TANK RETROFIT REPAIR FEE • $78.00/hour it hours min./FACILITY) • $234.00 mini mux IT <br /> R <br /> PIPING REPAIR FEE a $7E.00/hour (3 hours minlmuA/FACILITY) a 5234.00 mini mn 9 <br /> N TRANSFER FEE • $20.00 UNAUTHORIZED RELEASE EVALUATION • 378.00/hr 2 <br /> I <br /> S <br /> C CONSULTATION FEE • 178.00/hr SAMPLING INSPECTION FEE • 378.00/hr f <br /> TOTAL DUE t 13.1 <br /> FOR office USE ONLY - <br /> wiiwGY Y� C at"m5iw`we�i 5G3aw""•�•�«,..�w�w:ww"r�:nw«i::iww wiw�`:•�w"riw w•ww:w iww:iiwnf.'�ww"'•_w•_•_...•w i:w iww'.�i w�iw•wwGC <br /> � ��� � "D)-S�NI�s A1fdIIf�1I�"�IEIf TM@L'{�N9JCif1IP"e e1thJl�A�CdE"�'t`aFNa m����mm mr i <br /> .....____ _ ae•rwN�7Y <br /> wriFs�"at{A wwMw M sawiFa�alMawil���a11•MM���M�M�111111tsa�we••iYi ewrw�C •ea"a a'•siFwea�ism�li�t"•ialasirm`ess wm�ilMwwawirw <br /> �.W•«- a11a1MMaMMIYmM mMta <br /> EN 23 032 (REVISED 3-1-931 `� Paas 11 \�� <br />