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L SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE--- <br />ENVIRONMENTAL <br />ERVICE_ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />R <br />E <br />FACILITY SITE NAME <br />TANK I.D. #(s) Z D 7S — O / <br />C <br />L <br />FACILITY CONTACT NAME <br /># TANK(s)X $159.00 <br />F <br />0 <br /># TANK(s) X $159.00 = <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review/inspections) <br />TANK I.D. #(s) <br />R <br />E <br />_ �1 <br /># TANK(s) X 5150.00 = <br />S <br />_ $53.00 per hour (3 hour minimum per <br />facility = $159.00) S <br />P PLAN CHECK (Install. Plan Review & Construction Inspections) <br />TANK I.D. #(s) D �— <br />L <br />A I•k <br />N PLAN CHECK FEE - $53.00 per hour (8 hours mini mm per Facility) = $424.00 mini mm <br />is N24•D® <br />1 <br />FACILITY ADDRESS <br />EVALUATION <br />SAMPLING INSPECTION <br />SITE PHONE # with AREA CODE <br />I FEE = $53.00/hr <br />FEE = $53.00/hr <br />FEE = $ 53.00/hr <br />T <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />SITE <br />Y <br />Z-010/ <br />at <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />P <br />q. <br />ti <br />-:. <br />I <br />MAILING ADDRESS <br />qF-CEIVE D <br />APPLICANT PHONE # WITH AREA CODE <br />C <br />GVV <br />A <br />N <br />CITY <br />JAM <br />STATE <br />ZIP CODE TYP APPLI <br />T <br />..,, .,'d J�AQI'jN �.011NT, <br />CLOSUR STALLATI etc. <br />TOTAL <br />A <br />C <br />1986 <br />1987 <br />1 1988 <br />1 1989 <br />1990 <br />T <br />ANNUAL FACILITY FEE (Prior to <br />January 1, 1991) _ $100.00 /Yit. <br />I <br />$ <br />V <br />E <br />TANK FEE _ $50.00/TANK <br />(prior to January 1,1991) <br />$170/TANK <br />(after <br />January <br />1, 1991) <br />F <br /># Tanks = <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />1 1991 1 1992 <br />1993 1 1994 1 1995 <br />1996 <br />A <br />(mltipLy # by fee for <br />C <br />each year applicable) <br />I <br />L <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />I <br />T <br /># Tanks I x $56.00 <br />1986 through 1990 <br />1991 through 1996 <br />Y <br />(enter amount and year) <br />_ <br />R <br />E <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) <br />TANK I.D. #(s) Z D 7S — O / <br />C <br />L <br />CLOSURE FEE =-'$53.00 per hour (3 hours minimum per TANK) <br /># TANK(s)X $159.00 <br />$53.00 per hour (3 hours minimuVTANK) <br />0 <br /># TANK(s) X $159.00 = <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review/inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br /># TANK(s) X 5150.00 = <br />S <br />_ $53.00 per hour (3 hour minimum per <br />facility = $159.00) S <br />P PLAN CHECK (Install. Plan Review & Construction Inspections) <br />TANK I.D. #(s) D �— <br />L <br />A I•k <br />N PLAN CHECK FEE - $53.00 per hour (8 hours mini mm per Facility) = $424.00 mini mm <br />is N24•D® <br />R <br />E <br />REPAIR FEE (workplan review & construction inspections) <br />TANK I.D. #(s) <br />P <br />A <br />TANK REPAIR FEE = <br />$53.00 per hour (3 hours minimuVTANK) <br /># TANK(s) X $159.00 = <br />$ <br />I <br />R <br />PIPING REPAIR FEE <br />_ $53.00 per hour (3 hour minimum per <br />facility = $159.00) S <br />MCONSULTATIONS <br />I <br />S <br />UNAUTHORIZED RELEASE <br />EVALUATION <br />SAMPLING INSPECTION <br />C <br />I FEE = $53.00/hr <br />FEE = $53.00/hr <br />FEE = $ 53.00/hr <br />TOTAL DUE E 5 Oi <br />OFFICE USE ONLY <br />EH 23 032 (REV 1/10/91) ft Paoe 11 <br />