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- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TAI'IK PROGRAM -FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I �p �1 <br /> T SITE PHONE with AREA CQDE <br /> E FACILITY ADDRESS <br /> & STATE ZIP CIDE I of TANKS <br /> A <br /> CITY r. I at SITE <br /> f\ <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME T.- �r; <br /> L � � <br /> I APPLICANT PHONE I WITH ARE CODE <br /> qL <br /> C MAILING ADDRESS t��\A.; _ <br /> A <br /> N TYPE of APPLICATION <br /> STATE ZIP CODE <br /> T CITY r I CP, 5z� (Closure, InstalLation, etc_) Gl 05VAF— <br /> Iv TOTAL <br /> AlTANK FEE = 550.00/7ANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> C1986 1987 11988 1989 11990 1991 , 1992 1993 1994 11995 1996 <br /> T # Tanks = <br /> I <br /> eachtyear a�caoLe)fee r I XXXX ! XXXX XXXX I XXXX XXXX $ <br /> E TANK PENALTY FEES ASSESSED XXXX XXXX XXXX ! XXXXT XXXX I I 5 <br /> S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Cade, Section 25287 <br /> T1986 through 1990 1991 through 1996 <br /> E * Tanks x 556.00 <br /> (Enter amount and year) I 3 <br /> i <br /> C; PERMANENT CLOSURE (Remova( or Authorized Closure-in-Place} TANK L.D. -W(S)L 9 TANK(s) X 5734.00 = 5 �il <br /> O� CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) — — <br /> S I TANK I.O. �(s) <br /> Ul TEMPORARY CLOSURE (Pian Review & Inspections) <br /> R $ <br /> E TEMPORARY CLOSURE FEE = S78-00/hour (3 hours minimum/FACILITY) I $234.00 minimum <br /> P1 INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. 9(s) <br /> Al = 5624.00 minimum 3 <br /> N` PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br /> R REPAIR F=E (Workp(an Review & Construction Inspections) TANK I.D. »(s) <br /> EX 5234.00 = 3 <br /> P TANK LINING REPAIR FEE = 378.00/hour (3 hours mini xm/TANK) ` 9 TANK(s) <br /> A _ = 3234.00 minimum S <br /> I TANK RETROFIT REPAIR FEc = S78.00/hour (3 hours min./FACILITY} <br /> R t = $234.00 minimum $ <br /> j PIPING REPAIR FE = 378.00/hour (3 hours minimum/FAC.L]TY} <br /> MI TRANSFER FEE <br /> 520.00 , UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I 5 <br /> I <br /> Cl CONSULTATION FEE = $78.00/hr ` SAMPLING INSPECTION FEE <br /> L -V <br /> TOTAL DILE L{ <br /> iiiviiii-2........,:;::....__..._c...J.».. I I <br /> ., <br /> SWEEPS COf"PUT�iZ �LOC COO DIS <br /> i7-iST�COD A144UN1� ECfIV� L}SECK /CASH R>C�CIVEDY DAT REC V <br /> - - N <br /> ....... <br /> FH 23 046 (Revised 9/11/96) Page 11 <br />