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i SAN JOAQUIN COUNTYSLIC HEALTH SERVICES - ENVIRONMENTAL HEALTf low <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY.✓SITE NAME FACILITY CONTACT NAME _ <br /> i <br /> SA ri.=itAi j..,U L I L c i bete: <br /> •E SITE PHONE # with AREA CODE <br /> FACILITY ADDRESS <br /> & CITY STAT ZIP COD # of TANKS <br /> A 4; I do r- .Z. at SITE <br /> PAPPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS .� 1 �-.� �/ 2C '7 <br /> PPLICATION ' <br /> M CITY '7 - `7 AIE C� OE TClasure,I Installation, etc.) r_ ,t p1�F-�.- <br /> L.Ci!!r, 1PJ/_ > D TOTAL <br /> 1986 1987 1 1988 1989F!y <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 2100.00 xxxx xxxx X%xx A <br /> C xxxx xxxx xxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I <br /> 2170/TANK (After January 1, 199 1) <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> = 5 <br /> F (mil ti ply ir�f ee for xxxx XXXX X%XX <br /> A each year applicable) 2 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXx% %X%% I %XXX <br /> L <br /> I STATE SURCHARGE = 256.00 each TANK (Due every 5 years) See California N 8 S Code, Section 2528 <br /> T 1986 through 1990 1991 through 1996 <br /> Y # Tanks x 256.00 2 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) 2 <br /> ( # TANK(s) X 5234.00 = <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) 2 <br /> R <br /> E TEMPORARY CLOSURE FEE = 278.00/hour (3 hours minimum/FACILITY) 2234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(S) <br /> L <br /> minimum/FACILITY) <br /> A = 5624.00 minimum 5 <br /> N PLAN CHECK FEE = 578.00/hour (8 hours <br /> TANK I.D. #C s) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) 5 <br /> E <br /> TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # T$234 X 2234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE 278.00/hour (3 hours min./FACILITY) = $234.00 minimtm 2 <br /> R = 5234.00 minimum <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br /> S <br /> M TRANSFER FEE = 220.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr --- <br /> IS <br /> S = 578.00/hr <br /> C CONSULiATiON FEE = 575.00/hr SAMPLING INSPECTION FEE TOTAL DUE 2 <br /> ` i <br /> T...—,:., �: rd=r:_:,—rm.,a-:-,.^._:?yam.=:::::?:::::::::.::....r...:.:.,....::.::........:.::_...::�•_::___:_....... ._.. .:...... <br /> :.._....:::_:::::::-:.:..:.:.............:.._...;....._...._...:._.:.... ..:..,... E kE[EI'vEd " <br /> L'AECK #/CAsil k e IVE�'dV dA ;ij <br /> SG 'E6S f�- -COMPUTEf # -LOC C'OOE_ ._._dIST C'G6E- hMOitA'T-RE'Cl'CVE <br /> :� r rmn:e:�-.xm=-:_.......... ...................__........................_..............._.tteeEE:- t[��[[[[i[[e" a ._:..........._.:....._.:._:.:_.: ........._._....... <br /> EH 23 032 (REVISED 4-29-94) <br /> Page 11 <br />