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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> S FACILITY SITE NAME <br /> I eL elJ r FACILITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS (+� ( S PHON # with AREA CODE <br /> CITY ( eve ATE ZIP CODE at SITE A l / I <br /> P `-C <br /> P <br /> FLA <br /> ILLING NAM APPLIC T CONTACT E <br /> L <br /> I LM 2 <br /> C MAIL NG ADDR <br /> N SS PLIC NT PHONE # WITH AREA CODE <br /> A �. <br /> - 9 to <br /> T CITY TATE ZIP COD PLICATION <br /> Closur Installation, etc.) <br /> TOTAL <br /> A TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> C <br /> T # Tanks = 19 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> I (multiply if-6y-fee for <br /> E each year applicable) XX%K86 XXXX XXXX XXX% XXX% $ <br /> TANK PENALTY FEES ASSESSED I XXXX XXXX XXX% XXXX XXXX 5 <br /> S <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See Califor <br /> T nia H & S Code, Section 25287 <br /> E # Tanks x 856.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> E <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) <br /> S <. % $234.00 = 5 <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) <br /> R TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 mini"mum g <br /> L INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum $ <br /> R REPAIR FEE (workplan Review 8 Construction Inspections) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum g <br /> M <br /> I TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr g <br /> S <br /> ClCONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr $ <br /> TOTAL DUE 9 <br /> ...._.__...............................---.._...__......... .. <br /> ul- <br /> ...............: :..... ......_.....:..:::-::iii <br /> SUEEPs # COMPUTE # Lot coDE rirSY �OOE AMtlUN'r k@CETGEIS"""'cNE'Cf:-'#/tA'Srl"""' iFEt�'rGEb'-gy-`� -_-tid1`E!"RE��'fV`@6_....._.._.: <br /> r <br /> r m <br /> .:::.:.::::::::::1:.: <br /> .i <br /> EH 23 046- (Revised 7/10/96) Page 11 • <br />