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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDERGROUND STORAGE TANK P - FEE WORKSHEET <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />p <br />1U0i L— e� - <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />2. c> ) dam' " ►� <br /># TANK(s) X 5234.00 = <br />CITY <br />G ua�I <br />STATE <br />C.A <br />ZIP CODE <br />l52.1 ci <br />0 of TANKS <br />at SITE <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />>� S <br />L� <br />MAILING ADDRESS <br />2-'K'FCCa --s L,. <br />APPLICANT PHONE # WITH AREA CODE <br />C:i i <br />v f e-? l ✓ <br />1 Ll — 2—" L- L-4 <br />CITY <br />STATE <br />Z%P CODE TYPE of APPLICATION <br />c� <br />cel,-I`,,,iy (Closure, Installation, etc.) a 1 <br />TOTAL <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)l TANK E.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />E <br />1986 1987 1988 <br />1 <br />1989 1990 <br />1 <br />ANNUAL FAC%CITY FEE (Prior t0 January 1, 1991) = 5100.00 <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimun/TANK) <br /># TANK(s) X 5234.00 = <br />S <br />A <br />XXXX )0= XXXX <br />S <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX XXXX xxxx <br />= S234.00 minimum <br />S <br />s TANK FEE = S50.00/TANK (Prior to January 1,1991) <br />5170/YANK (After January <br />1, 1991) <br />S <br />E <br />0 Tanks 1 1986 1987 1988 ( 1989 <br />1990 1991 119921993 1994 1 <br />1995 1 1996 <br />F (multiply fee for <br />i <br />C <br />A each year app icable) XXXX XXXx )0= <br />= S78.00/hr I <br />S <br />S <br />I TANK PENALTY FEES ASSESSED I XXXX =(X ( XXXX I <br />I <br />S <br />S <br />i STATE SURCHARGE = $56.00 each TANK (Due every 5 years) <br />See California H & S Code, Section 25287 <br />f # Tanks x S56.00 <br />1986 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)l TANK E.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimun/TANK) <br /># TANK(s) X 5234.00 = <br />S <br />A <br />I <br />R <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum <br />S <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum <br />S <br />' N <br />I <br />TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I <br />S <br />i <br />C <br />CONSULTATION FEE = S78.00/hr I ( SAMPLING INSPECTION FEE <br />= S78.00/hr I <br />S <br />TOTAL DUE <br />S <br />EN 23 032 (REVISED 4-29-94) Page 11 <br />