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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br />"MOERGROUND STORAGE TANK PROGRAM - FEE WORKSHF-T <br />S <br />FACILITY SITE NAME <br />FACILITY FACT NAME <br />T <br />/ <br />7- #" , � 117 4v <br />C . E a) 1-5 <br />L <br />A <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br /># TANK(s) X 5234.00 = <br />S <br />A <br />I <br />S <br />S <br />P <br />CITY G� 2 <br />.iJ r �/¢ �' /��.J-�� <br />STATE <br />ZIP CODE <br /># of TANKS <br />at SITE ,:3 <br />$ <br />R <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />I <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />) <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />" <br />N <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />v� / 7i _ <br />`�% <br />— <br />(Closure, Installation, etc.) <br />TOTAL <br />1986 1987 1988 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />A XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br />C <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br />I <br />V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br />E <br /># Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />F (multiply # by fee for <br />A each year app(icable) XXXX XXXX XXXX XXXX XXXX S <br />C <br />I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX I S <br />L <br />I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y # Tanks x 556.00 1988 through 1990 1991 through 1996 <br />(Enter amount and year) <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) <br />TANK I.D. #(s) <br />L <br />L <br />A <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />S <br />A <br />I <br />S <br />S <br />R <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />$ <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />TANK I.D. #(s) <br />L <br />E <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br />5 <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />$ <br />M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br />TOTAL DUE $,,-) � q. 27 �3s' <br />FOR OFFICE USE ONLY M <br />