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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UMDERGROUMD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> [ <br /> T / A c /�( c P,/, ..�iv d <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> A �' .� �(�6v` t✓9 �? Ze> at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A P. p , aF / { �Ll. _ <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> �.�-oc�C t.�.. k F,.�+c..:cam-('. <br /> �� g �,( (Closure, Installation, et <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX $ <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1 1996 <br /> F (multiply # by tee for <br /> A each year applicable) I $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX S <br /> L <br /> 1 STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) it TANK(s) X $234.00 = $ <br /> sl I <br /> U TEMPORARY CLOSURE (Plan iew & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> N TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = 578.00/hr $ " <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> SWEEPS # I COMPUTER #I`. LOC CODE DIST CODE I AMOUNT RECEIVED (CHECK_ CASH I RECEIVED BY DATE RECEIVED <br /> J�r <br /> e9 <br /> ,_ / 2_ -- <br /> EH 23 032 (REVISED 11-1-92) r Page 11 �..r <br />