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S._,OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A San Joaquin Delta College Toni Cardinale <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CCOE <br /> 1 5299 Brunswick Road (209) 239-5814 <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y CA 95207 at SITE <br /> ---- <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Pan Joaquin Delta College P S 4 g Toni Cardinale <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A 5151 Pacific Avenue (209) 485-3456 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I S <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks 1 1986 1987 1988 1 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (muLtiply Ifee for <br /> each year applicable) $ <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> f <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> f <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK [.D. #(s) <br /> C <br /> 0 CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(S)__2_ X $159.00 = f 318 . 0 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = $ <br /> PI PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum S <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = f <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M <br /> I TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $53.00/hr $ <br /> 5 <br /> C CONSULTATION FEE _ $53.00/hr SAMPLING INSPECTION FEE = f53.00/hr 5 <br /> TOTAL DUE S 8 - 00 <br /> OF FIG:E..USE::� N:Y::-,:::::---..—.-.-:::::::::._-:-:-:::::::::::-::::::::::::::::::::,::,,..._........,,...:,:::::::::::::::-::___:::::::.-:-::::-:r- ,:,:::,,-::::--.-...—:..:.::...:............._._. <br /> . ... ....... .. ... _ .,....... <br /> mi_i_iii";![t:isE_: _ ii's=ii='siii::'_'._:__===iii's=ii[[iiii::;:i[i=ay :: s;s;:s:aiiii::iiiiiiiaiEii ':: ==iii='siiiii[i'e ;[[iiii[[i[[r; = iiiii:_ii____:::._. :: :iii:[[:i_i[isii=_;:__stiise'i_'='.ii ':=. y ''[:`:[[i-yei__,i <br /> w suEEP$ !! coMauTEh #r LOC ObbEfi 1)tgT LODE 1 AMOUNT Rcw OHEO� GAS 60C <br /> kECEIVED lYY 600 REOEtVED <br /> EH 23 032 (REV 4/8/91) It <br /> PAYMENT <br /> RECEIVED <br /> JLN 0 5 1992 <br /> ,AN J0AQUIN Ci L:NTY <br /> PUBLIC iiEA:T'H:•E'�iCES <br /> f'.N WO iMEN7AL HEAL;4 DI'tiiSPv'.1 <br /> 9 <br />