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• <br /> SAN JOAQUINI COUNTY PUBLIC HEALTH SERVOIS <br /> ENVIRONMEENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> I FACILITY SITE NAME �� !s MIN 1 M FACILITY CONTACT NAME <br /> TSITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS 33oa V S7 LAN£ ZOQ (o(,o— 1(o -2— <br /> & <br /> & STATE2IP CODE # of TANKS <br /> A CITY gock--r'on) CPr q�2b(c at SITE 3 <br /> L APPLICANT.^/BILLINGNAME <br /> y �C4� APPLICANT CONTACT NAME <br /> `J'T I�1ll�E L� �ifb-375-11b8 <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A L9 oS IAV pec✓E <br /> N STATE ZIP CODE TYPE of APPLICATION C L0$(�2E <br /> T CITY ��GKZ I c�s�� (Closure, Installation, etc.) <br /> TOTAL <br /> A TANK FEE = s50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> C1986 1987 11988 1989 1990 1991 1992 11993 1994 1995 11996 <br /> T # Tanks = <br /> fee fo <br /> V eachtyear a p icable)r XXXX XXXX XXXX XXXX XXXX I ( I $ <br /> ETANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX <br /> S I I I I $ <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 2528 <br /> T1991 through 1996 <br /> EI # Tanks x $56.00 1986 through 1990 <br /> (Enter amount and year) $ <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. »<s) —I 2 3 <br /> X $234.00 = $ <br /> 01 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) I _ <br /> S <br /> Ul TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R $ <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br /> P1 INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. »(s) <br /> Al _ $624.00 minimum $ <br /> NI PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br /> Rl REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E $ <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) ( # TANK(s) X $234.00 <br /> A $ <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br /> R $ <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br /> Mi TRANSFER FEE _ $20.00 I UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> SI, <br /> ' $ <br /> C; CONSULTATION FEE _ S78.00 hr SAMPLING INSPECTION FEE = $78.00/hr <br /> TOTAL DUE <br /> _..F()R...Q.F..F..I GE...U. <br /> as <br /> -_.._.SUE PS i COMPUTES lOC CODE DISI-•CODC �AMOUNY�R<Ct_IVED �CHCCK i/CASH r f� CcIVD �Y DATC R(CCIN D <br /> y <br /> ...._.............._................_e-::::::::::..r. ...----._._.._.._ ... ... =: F^_ � _ —::::: <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />