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. , SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T S // <br /> T LG C� <br /> E FACILIT ADDRESS /, 9 SITE PHONE # With AREA CODE <br /> g <br /> CITY Sfo�� I STAT ZIP CODE /- # of TANKS <br /> A ``'L.Va_I',L./ /.J' �/[f� at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS BB APPLICANT PHONE # WITH AREA CODE <br /> N C� <br /> T CITYSTATZIP CODE (O — TD I <br /> ' Q (Closure, Installation, etc. <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A X%%X XXXX XXXX %XXX XXXX S X%%XXXX% <br /> C <br /> JE <br /> T -FACIIJ TY w v FFG eSSE SE0 [If AmLjcXXX% 1(X)(X %XX% XXXX %XX% S XXXXXXX% <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> 0 Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1 1998 <br /> F (multiply # by fee for <br /> A each year applicable) X%%% I %XXX I XXXX I XXXX XXXX - 5 <br /> C <br /> ITANK PENALTY FEES ASSESSED X%XX XXXX %XX% XXXX XX%X I S <br /> L <br /> TSTATE SURCHARGE FOR NEW FACILITIES ONLY_;*4Q /060 S 60 <br /> Y # Tanks—li x 58.00 1988 through 1993 (456) 1993 through 1997 (556) 1998 —^ , <br /> SURCHARGE FOR 1998 XXX%%XXXXXXXX%%XXXX%XXXXXX% XXXX%%XXX%%XXXX%XXXX%XX 5 C/.f1 <br /> CI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) V ' <br /> L <br /> Oj CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = 8 v Cn <br /> S' <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK 1.0. #(s) <br /> II <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 5 <br /> PIINSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L• <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum 5 <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr Lsi I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> ....... - -__ <br /> .. ..-_.:::. .:__:___:__...... _____—�:—__:__�:_::_._:..::___._:_:__::_:�_�:._,.,oma=;:-':a_ ___�_-�-s-�:::,..�:::ii::. �� - _ <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> ii <br /> a 5 <br /> nn <br /> EH 23 032 (REVISED 1-12-98) <br />