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0 a <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />A <br />FACILITY SITE NAME F:LA- A <br />�lX�.e+ �'✓' <br />`P1 G-. <br />F/CILITY CONTACT NAME ' <br />(✓G(U ,A Fi,.., i41,rPe <br />I <br />1991 1992 11993 1994 1995 11996 <br />I <br />f <br />e <br />TANK PENALTY FEES ASSESSED I XXXX XXXX XXXX I XXXX XXXX <br />I I <br />5 <br />T <br />E <br />FACILITY ADDRESS <br />i I Y,.- I j� rid <br />e <br />tj <br />$jT PHON #with ARPE�A CODE <br />.- <br />�� <br />& <br />CITY <br />/RTE <br />Za �,.°�.`2_ I atoSITENKS 2 <br />.d <br />A <br />CI <br />PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) <br />TANK I.D. #(s) <br />P <br />,-A—PPL & NAME <br />AJ I� I rJ - i,��r� <br />5 <br />APPLICANT CONTACT NAME <br />P1 L l -F L E <br />L <br />WA t�T"� r.3 <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />C <br />MAILING ADDRESS <br />po <br />.... <br />APPLICANT PHONE # WITHAREACODE <br />N <br />T <br />CITY <br />STATE <br />ZIP CODE TYPE of APPLICATION <br />(Closure, Installation, etc.) O <br />RI REPAIR FEE (Workplan Review & Construction Inspections) I <br />TANK I.D. #(s) <br />TnTni <br />A <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK (ATter January , <br />T <br />V <br /># Tanks = 1986 1987 11988 1989 1990 <br />tyear appLicable)r XXXX XXXX XXXX XXXX XXXX <br />eacht <br />1991 1992 11993 1994 1995 11996 <br />I <br />$ m <br />E <br />TANK PENALTY FEES ASSESSED I XXXX XXXX XXXX I XXXX XXXX <br />I I <br />5 <br />S <br />I <br />STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T1991 <br />E <br /># Tanks x $56.00 1986 through 1990 <br />(Enter amount and year) <br />through 1996 <br />S <br />CI <br />PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />5 <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) I <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />P) INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I <br />Al <br />N( PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />TANK I.D. #(s) <br />= 5624.00 minimum <br />S <br />RI REPAIR FEE (Workplan Review & Construction Inspections) I <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I <br />TANK(s) X 5234.00 = <br />5 <br />A5 <br />II <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum <br />R5 <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= 5234.00 minimum <br />MI TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />1 <br />5 <br />S5 <br />Cl <br />CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE <br />= S78.00/hr i <br />TOTAL DUE <br />EH 23 046 (Revised 7/10/96) Page 11 <br />