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' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM 'FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> S FACILITY SITE NAME Al <br /> I ,u <br /> SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS <br /> & CITY STAY ZIP CODE # of TANKS <br /> ^� at SITE <br /> A .ST 70AI CJS <br /> APPLICANT CONTACT NAME <br /> P APPL CANT/BILLING NAME <br /> L <br /> A MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> st Pn�� o� <br /> M STATE ZIP CODE TYPE of APPLICATION- e a-j <br /> T CITY c� ,rs (Closure; Installation, etc.) <br /> c0 TOTAL <br /> A TANK FEE = 550.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> C1986 1987 1988r 1989 1 1990 1991 1992 1993 1994 1995 1996 <br /> T # Tanks = fee for <br /> I (multiply $ <br /> V each year app ifee XXXX %%X)( XX%% X%%% XXXX <br /> - TANK PENALTY FEES ASSESSED I XXX% %XXX I XXX% I XXXX I X%XX <br /> S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> f T <br /> E # Tanks_ x 556.00 1986 through 1990 1991]through <br /> (Enter amount and year) 996g <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) # TANK(s)_ X $234.00 = $ <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours mininxWFACILITY) 5234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> -- <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspecticns) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimun/TANK) # TANK(a) _ X $234.00 = S <br /> AS <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> Rg <br /> PIPING REPAIR FEE = S78.DO/hour (3 hours mininKWFACILiTY) = $234.00 minimum <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> r <br /> 5g <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE <br /> #—r`c'ti'riPGYr'rs#'T�o�oDE� O15Y CODE 'AMo�NY-RE'CEIVEDTCNECK-#7�asH--R�tEtvEO BY�—Ol'I"�-REr1=INFO ;l <br /> m <br /> ;u <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />