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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDERGROMSTORAGE TANK PROGRAM - FEE WORKSHEET <br />TY CO <br />FAC <br />IITT SITE E FACILITY NAME <br />MNM I - ImiqlMaw--. I �- <br />AGILITY ADDRESS SITE PHONE I with AREA CODE <br />2-qo /'/, W*,) <br />1.' Y STATE ZIP CODE a of TANKS <br />at SITE <br />P <br />P APPLI T/BILLING NAME APPLLCANT CONTACT AME <br />L .—� <br />I _ c _ <br />C IHC AO APPLICANT PHONE # WITH AREA CODE <br />T CITY STATE ZIP CODE TYPE of APPLICATION <br />.-'� (Closure, Installation, etc.) <br />1 1 1 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100.00 1986 1987 1988 1989 1990 <br />A <br />C XXxX XXxx I S <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) <br />I XXxX I XxXX I I S <br />V TANK FEE = 150.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br />E <br /># Tanks = 1986 1987 1988 11989 11990 1991 1992 11993 1994 11995 11996 <br />F (multiply x by fee for <br />A each year applicable) XXXX Xxxx I I I I I S <br />C <br />I TANK PENALTY FEES ASSESSEDI XXXX XXXX I I X <br />L <br />I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H b S Code, Section 25287 <br />'T <br />T x Tanks x 156.00 1988 through 1990 1991 through 1996 <br />(Enter amount and year) <br />TOTAL <br />L <br />1--KRAncnu %.LU5uKt CKemOVal or Authorized Closure-in-Place)I TANK I.D. X(s) <br />0 <br />S <br />CLOSURE FEE = 178.00/hour (3 hours minimum/TANK) <br />X TANK(s) X 5234.00 = <br />S <br />U <br />R <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. X(s) <br />E <br />TEMPORARY -CLOSURE FEE = 178.00/hour (3 hours mini /FACILITY) <br />5234.00 minimum <br />3 <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. X(s) <br />A <br />N <br />PLAN CHECK FEE = 178.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />S <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. 3(s) <br />A <br />A <br />TANK LINING REPAIR FEE = 178.00/hour (3 hours minimum/TANK) I x TANK(s) X 5234.00 = <br />S <br />I <br />R <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />PIPING REPAIR FEE = 178.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />NI TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />I <br />S � I <br />C CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = X78.00/hr <br />S <br />S <br />TOTAL DUE S -/7 -?Cl e' <br />F01 ICE USE ONLY <br />WEEPS x I COMPUTER x I LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK X/CASH I RECEIVED 3Y I DATE RECEIVED <br />IEH 23 032 (REVISED 10-28-93) <br />3 <br />C <br />Y <br />Y <br />Y <br />