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i <br /> r , <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> EFACILITY SITE NAME FACILIT�3TACT NAME <br /> [ P <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & W1 S - <br /> AlCITY STATE ZIP CODE # of TANKS <br /> 5 T.C,KjQ r ' 5 < sZ 5 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT AME <br /> L ( Til- T <br /> I <br /> AMAILING ADDRESS ,l N` APPLICANT PHONE # WITH AR CODE <br /> N vW L AV <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> S � ��. 5zc) (Closure, Installation, etc.) GIOSVI{� <br /> TOTAL <br /> A TANK FEE = 550-00/7ANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> C <br /> T # Tanks = yy 1986 1987 1988 1989 1990 1991 1992 11993 1994 11995 1996 <br /> Eeachtyear applicable)fee r XXXX I xxxx I xxxx XXXX XXXX E <br /> TANK PENALTY FEES ASSESSED XXxx I XXXK XXXX I xxxx XXXx S <br /> S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> E # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> E <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) I TANK L.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 5 <br /> S. <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. #(s) <br /> Ei TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimim/FACILITY) I $234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> Al <br /> NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 <br /> IIREPAIR FEE (Workp(an Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = S <br /> Al <br /> II TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> RI <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimus E <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr E <br /> i <br /> 5 <br /> C1 CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> Ll <br /> u.c <br /> TOTAL WE Ll L-9` <br /> _EOtt_....FF...C,E:::: <br /> ' :......::i::::::::- ::::_:iiiieiii:i:�:--:•_x:::::::::c:_=e:::_::o :::_:::_-_—s-_:_.::_—•_-- _:�::_=::=:r.—_=;c_. i::?ii3::-:__:::::_:-:::::_.N <br /> SW PS 9 r 2oMPl-TER ':2—I LOC—C06EE:b'iSYTODE�MOUNT tECE16E0�[HECK #/CASH �REC"c7VEb 9Y DATB RECEIVED <br /> ii <br /> r - <br /> EH 23 046 (Revised 9/11/96) Page 11 <br />