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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET 112 <br /> S FACj.I,I iY SITE NAME FACILITY CONTACT NAME <br /> I Tyeli e er <br /> T <br /> E FACILITY ADDRESS SIHONE 0 with EA CODE <br /> TE <br /> e <br /> CITY STATE ZIP CODE K ofTANKS <br /> A (/J at St TE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE M WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1 1987 1 1988 1989 1 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A XXX% %X%X <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xX%X xxxx $ <br /> I <br /> V TANK FEE _ 150.00/TANK (Prior to January 1,1991) 1170/TANK (After January ' Inn <br /> E <br /> 2 Tanks = 1986 1 1987 1 1988 1989 1990 1991 1992 1993 1994 1995 1 TN <br /> L(mitipty K by fee for ES <br /> r applicable) xxxx xxxxLTY FEET ASSESSEDXXXX XxxxCHARGE • $56.00 each TANK (Due every 5 years) fee California H 6 5 Code, lection 25287 <br /> x ,56.00 1988 through 1990 1991 through 1996 <br /> ount end year) <br /> S&O� rz Oar f �� <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. M(a) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimaNTANK) Y TANK(s)_ X $234.00 - f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review d Inspections) TANK I.D. M(a) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) 0 TANK(s) X (234.00 - f <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. M(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum It <br /> R REPAIR FEE (Workplan Review 4 Construction Inspections) TANK I.D. A(a) <br /> E <br /> P TANK LINING REPAIR FEE - S78.00/hour (3 hours minimum/TANK) R TANK(s) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) - $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 278.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum f <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = !78.00/hr , <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ %78.00/hr $ <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY 7(.)t_A �.{ bzG4G/(s�t <br /> ... _m.=............... ..__.._._..__...____..__........_..._._..........._.......__._..._..._... : :: ...... .. ...:. .:._.__T.._" <br /> SWEEPS s COMPUTER R LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH RECEIVED BY DATE RECEIVED <br /> f <br /> '.,,:. .,:-......—:..,.T....._..-,_.gin-.. :_.:_....._.....___,.--_-. ., __ -_ - ":-- !_ -�!--"'-- !_::_ <br /> .__.._.__..._.................a......__......._._.-_..._..___..__._.._..._...... .:..........._......... .............-rt.—..-a ___ __ _ _ __ _ 3 <br /> ...e......::.::::... .:......v::..:..:...:.:..:::::..:::....... <br /> EN 23 032 (REVISED 6-21-93) Page 11 <br />