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SAN JOAQUIN CDUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIMON <br /> UNDERGRa= STORAGE TANK PROGRAM - FEE WORXSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAM <br /> T J / <br /> E FACILITY DRESS SITE PHONE ? with AREA CODE <br /> & S . 09 ,1 y <br /> CITY STATE ZIP CODE # o TANKS <br /> A \> at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C NAILING ADDRESS APPLICANT PHONE X WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYP PLICATION <br /> -(Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX X)= S <br /> C <br /> 7 FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX XXXX S <br /> I <br /> V TANK FEE • 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> r Tanks = 1986 1 1987 1988 1989 1990 1991 11992 1993 1994 11995 1996 <br /> F (multiply x by fee for <br /> A each year applicable) )0= )C= S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX I I 5 <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y X Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorised Ctosure-in-Place) TANK I.D. 9(s) <br /> L <br /> 0 CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) x TANK(s)3 X 5234,00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) - TANK 1.0. 4(S) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.001hour (3 hours mini=AVFACILLTY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction (nspeetiona) TANK I.O. $(a) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK t.D. 4(s) <br /> E <br /> l. <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) d TANK(s) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr I 5 <br /> I <br /> S <br /> CI CONSULTA720N FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS d CONFUTER d LOC CODE I DIST CODE I AMOUNT RECEIVED CHECKS/CASH 2ECEIVED dY DATE RECEIVED <br /> EN 23 032 (REVISED 10-28-93) Page 11 <br />