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SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />P� <br />FACT U Y SITE NAME I <br />FACILITY CONTACT NAME <br />I+ <br />TOTAL <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />T <br />E <br />FACILITY ADDRESS i <br />%� % !�!r( <br />SITE PHONE #,/with AREA CODE <br />� 0 % % � — 7 3 J <br />A <br />CITY//_� <br />STATE <br />C4 <br />ZIP CODE <br />9572 f 7 <br /># of TANKS <br />at SITE <br />to January 1, 1991) = $100.00 <br />? Z) <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />_ 5t / J 0 % � Sllj <br />Lr <br />A- i i� 7- L ,� C? <br />® <br />I <br />MAILFG ADDRESS <br />APPLICANT PHONE #WIT�CSEAfn <br />C <br />T <br />�L-" ('/C, <br />��8�� <br />N <br />T) <br />CfTY�-- <br />i Z, /� <br />STATE <br />e <br />ZIP CODE <br />TYPE of APPLI <br />(Closure, 115:t allati , etc.) <br />P� <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />P <br />TOTAL <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />S <br />1986 11987 11988 <br />11989 <br />11990 <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) = $100.00 <br />A <br />x)00( =(x <br />S <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />xxxx xxxx <br />( <br />I <br />S <br />I <br />V <br />TANK FEE = S50.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK (After <br />January <br />1, 1991) <br />E <br /># Tanks = <br />1986 <br />1987 <br />1988 1989 ( <br />1990 1991 1992 1993 <br />1994 11995 <br />11996 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />xxxx <br />xxxx <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />( xxxx <br />xxxx <br />I <br />I <br />5 <br />L <br />11 <br />STATE SURCHARGE = S56.00 <br />each TANK (Due every 5 years) <br />See California H & S Code, <br />Section <br />25287 <br />T <br />Y <br /># Tanks x 556.00 <br />1988 through 1990 <br />1991 through <br />1996 <br />(Enter ; unt and year) <br />t <br />P� <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />S <br />RN <br />REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = <br />S <br />A <br />ItANK <br />RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br />S <br />NI TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I $ <br />I I i <br />S <br />C1 CONSULTATION FEE = 578.00/hr ( SAMPLING INSPECTION FEE = S78.00/hr S <br />TOTAL DUE 15 <br />FOR OFFICE USE ONLY <br />•v=im.... .......__.Y.---=. — -- - ——- <br />:: • rx'iimesn •�•rm' u'i=a .s••-is�---r -- ren ��-i.�---.___"�'-:z••---;.•�m.�•._^ _ "' <br />SWEEPS # COMPUTER I LOC CODE I DIST CODE AMOUNT RECEIVED CHECK */CASH I RECEIVED 3Y I DATE RECEIVED <br />EH 23 032 (REVISED 10-28-93) 3 <br />