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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EYVIRONIVIENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHF_F'T' <br /> ( FACILITY SITE NAME 1../ 1 FACILE YY CONTACT NAME 1� <br /> Tel� CC <br /> E FACILITY ADDRESS N SITEPHO E gwi h AR CODE <br /> a 1 <br /> CITY tVNE P CODE 6 of TANKS <br /> ATRA�tllat SITE <br /> v <br /> APPLICANT/BILLING NAME APPLICANT CONTACT AME <br /> L <br /> I <br /> C MAILING ADDRESS ^ APPLICANT PHONE R VITH AREA CODE <br /> A (� <br /> M <br /> TI CITY Rpp��AL. ST TE. ZIP COO E of APPLICATION <br /> 3 (Closure, Installation, etc.) <br /> TOTAL <br /> Al TANK FEE 550.00/TARK (Prior to January 1,1991) 5170/TANK (After,4" 1, 1991) <br /> C' <br /> T 7 Tanks = 1986 1987 11988 1989 1990 1991 1992 1 11994 11995 1996 <br /> 1 (multiplyyyfee for <br /> E each year applicaole) XXXX XXXX I XXXX XXXX XXXX I S <br /> S TANK PENALTY FEES ASSESSED I X)= XXX% I XXXX rw )0= I I 5 <br /> T STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See Califo is H a S Code, Section 25287 <br /> E X Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 5 <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace TANK I.D. p(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) X TANK(s)_ X 5234.00 = 5 D'17 <br /> S' <br /> UI TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.D. k(s) <br /> R <br /> El TEMPORARY CLOSURE FEE - 578.00/hour (3 hours mini FACILITY) 5234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review a Const tion Inspections) TANK I.D. $(a) <br /> L' <br /> AI <br /> MI PUN CHECK FEE = 578.00/hour (8 hours min' FACILITY) 5624.00 minimum 5 <br /> V REPAIR FEE (workplan Review a Constru ion Inspections) TANK 1.0. x(5) <br /> E <br /> P rK <br /> LINING REPAIR FEE • 578.00/hou (3 hours minimum/TANK) k TANK(s) X 5234.00 5 <br /> A <br /> 1 TANK RETROFIT REPAIR FEE - 578.00 our (3 hours min./FACILITY) = 5234.00 minimum 5 <br /> R <br /> PIPING REPAIR F _ <br /> -c 578.00/hour 3 hours minimm/FACILITY) = 5234.00 minimum S <br /> MI TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> IrS <br /> Cl CONSULTATION FEE = S78.0011r I I SAMPLING INSPECTION FEE - 578.00/hre14� I ��- <br /> TOTAL DUE <br /> 8 7K . <br /> � 5a = oo <br /> —E46.-Qf ELCE-USE-ON.LY <br /> s SvE"c?S;�C' 1iDUY�Ci r�-OC CCOE�DTST 100 AM`0UN'i��FECETGEO C4E'G��C,SH "cZ:="IT/EI)8Y�—DATE�REE�IyEb�3 <br /> EH 23 046 (Revised 7/10/96) Page 11 0 <br />