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FACILITY SITE NAME T c) E FACILITY ADDRESS & CITY POt, PANT ILLING NAME LT J" C4 I —' ADDRESS SAN JOAQUIN JNTY PUBLIC HEALTH SERVICES - ENVIRONMENTA, ALTH DIVISION UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET FACILITY CONTACT NAME SITE PHONE # with AREA CODE STATE ZIP CODE # of TANKS C� vv -y at SITE APPLICANT CONTNAME alp APPLICANT PHONE # WITH AREA CODE A MA �U� `7 V Gn ? ._ l %�`�r33_3 N STATE ZIP CODE TYPE of APPLICATION T CITY ---A e:�o '—, ! (Closure, Installation, etc.) TOTAL C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) LX $234.00 = 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. »(s) R E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A = $624.00 minimum N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) EX $234.00 = P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) A I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum R PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum M TRANSFER FEE _ $20.00 I UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I Ii $ S = $78.00/hr 15 C CONSULTATION FEE _ $78.00/hr I SAMPLING INSPECTION FEE TOTAL DUE FOR OFFICE USE ONLY _ __ _ — __ _;:—.--..........._::::-----.=.a:-::-:—:----:s=.-:::::::_::_.:'.:::::::...... ��—�� _::::::: _ ::-:::::::::::_-:::::: ::::::: t:::::;::::::t:[ ::::t t :::i__ _s__ €i i '.........i_ E iiii'siii€_ ii€i€ i -i'ss€ _s=r:r_:::t:_::_:::: s st:::a::::::::::::-:::::::::::::::I .VE:D:::::::_:::::: ............... ..............._....................._. _.. _ __._. r _ --- _ SWEEPS » COMPUTER » LOC CODE DIST CODE AMOUNT RECEIVED CHECK »/CASH RECEIVED BY DATE RECEIVED ............'::::::.....::::::::.-s:: 1986 1987 1988 119#1990ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 XXXX XXXX XXXX XX $ XXXXXXXXXXXXX A CT FACILITY PENALTY FEES ASSESSED (lf Applicable) XXXX XXXX XXXX XX 5 XXXXXXXXXXXXX I V TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) E 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 # Tanks = F (multiply # by fee for S I A each year applicable) XXXX XXXX XXXX XXXX XXXX I C 1 TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ L 1 STATE SURCHARGE = $56.00 each TANK (Due every -5 years) See California H & S Code, Section 25287 T1991 Y # Tanks x $56.00 1988 through 1990 through 1996 (Enter amount and year) $ C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) LX $234.00 = 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. »(s) R E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A = $624.00 minimum N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) EX $234.00 = P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) A I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum R PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum M TRANSFER FEE _ $20.00 I UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I Ii $ S = $78.00/hr 15 C CONSULTATION FEE _ $78.00/hr I SAMPLING INSPECTION FEE TOTAL DUE FOR OFFICE USE ONLY _ __ _ — __ _;:—.--..........._::::-----.=.a:-::-:—:----:s=.-:::::::_::_.:'.:::::::...... ��—�� _::::::: _ ::-:::::::::::_-:::::: ::::::: t:::::;::::::t:[ ::::t t :::i__ _s__ €i i '.........i_ E iiii'siii€_ ii€i€ i -i'ss€ _s=r:r_:::t:_::_:::: s st:::a::::::::::::-:::::::::::::::I .VE:D:::::::_:::::: ............... ..............._....................._. _.. _ __._. r _ --- _ SWEEPS » COMPUTER » LOC CODE DIST CODE AMOUNT RECEIVED CHECK »/CASH RECEIVED BY DATE RECEIVED ............'::::::.....::::::::.-s::