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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - MIROM ENTAL HEALTH DIVSIONUD UDERGROSTORAGE TANK PROGRAM- FEE WORKSHEET /FST -FA C ILITY SITE NAME FACILITY CONTACT NAME ' (T -- I `� 5fo 7� v C 1 T E FACILITY ADDRESS 1 SITE PHONE 0 with AREA CODE CITY STATE ZIP CODE 0 of TANKS A r1 C �j at SITE P / i'' P APPLICANT/B LLING NAME APPLICANT CONTACT NAME L 1 C MAILING ADDRESS APPLICANT PHONE if WITH AREA CODE A N T CITY STATE ZIP CODE TYPE of APPLICATION (Closure, Installation, etc.) TnTAI ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 1986 1987 1988 1989 1990 A $ C T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S I V TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E N Tanks_ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 F (multiply # y fee for A each year applicable) I TANK PENALTY FEES ASSESSED XXXX XXXX $ L P Lj I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H b S Code, Section 2 7 T Y # Tanks x $56.00 1986 through 1990 1991 through 1996 (Enter amount and year) $ C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. 0(s) L 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) $ TANK(s) X $234.0 IRONME � HEALTH S U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. N(s) R E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) N TANK(s) X $234.00 S P INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) 5624.00 minimum S R REPAIR FEE (Workp(an Review R Construction Inspections) TANK I.D. *(s) E P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) 0 TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum % R PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ M TRANSFER FEE ■ S20.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr-- I S C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S ' 7 TOTAL DUE FOR OFFICE USE ONLY ................ ............. .............•...u•.u..�:��u::::::uvvvvvm 1 • ip' 'tl ' ltYt' SWEEPS (f COMPUTER 0_1 LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK VCASH EH 23 032 (REVISED 11-1-92) page 09 RECEIVED BY 2, DATE RECEIVED TnTAI ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 1986 1987 1988 1989 1990 A $ C T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S I V TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E N Tanks_ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 F (multiply # y fee for A each year applicable) I TANK PENALTY FEES ASSESSED XXXX XXXX $ L P Lj I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H b S Code, Section 2 7 T Y # Tanks x $56.00 1986 through 1990 1991 through 1996 (Enter amount and year) $ C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. 0(s) L 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) $ TANK(s) X $234.0 IRONME � HEALTH S U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. N(s) R E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) N TANK(s) X $234.00 S P INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) 5624.00 minimum S R REPAIR FEE (Workp(an Review R Construction Inspections) TANK I.D. *(s) E P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) 0 TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum % R PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ M TRANSFER FEE ■ S20.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr-- I S C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S ' 7 TOTAL DUE FOR OFFICE USE ONLY ................ ............. .............•...u•.u..�:��u::::::uvvvvvm 1 • ip' 'tl ' ltYt' SWEEPS (f COMPUTER 0_1 LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK VCASH EH 23 032 (REVISED 11-1-92) page 09 RECEIVED BY 2, DATE RECEIVED C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. 0(s) L 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) $ TANK(s) X $234.0 IRONME � HEALTH S U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. N(s) R E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) N TANK(s) X $234.00 S P INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) 5624.00 minimum S R REPAIR FEE (Workp(an Review R Construction Inspections) TANK I.D. *(s) E P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) 0 TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum % R PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ M TRANSFER FEE ■ S20.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr-- I S C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S ' 7 TOTAL DUE FOR OFFICE USE ONLY ................ ............. .............•...u•.u..�:��u::::::uvvvvvm 1 • ip' 'tl ' ltYt' SWEEPS (f COMPUTER 0_1 LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK VCASH EH 23 032 (REVISED 11-1-92) page 09 RECEIVED BY 2, DATE RECEIVED P INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) 5624.00 minimum S R REPAIR FEE (Workp(an Review R Construction Inspections) TANK I.D. *(s) E P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) 0 TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum % R PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ M TRANSFER FEE ■ S20.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr-- I S C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S ' 7 TOTAL DUE FOR OFFICE USE ONLY ................ ............. .............•...u•.u..�:��u::::::uvvvvvm 1 • ip' 'tl ' ltYt' SWEEPS (f COMPUTER 0_1 LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK VCASH EH 23 032 (REVISED 11-1-92) page 09 RECEIVED BY 2, DATE RECEIVED R REPAIR FEE (Workp(an Review R Construction Inspections) TANK I.D. *(s) E P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) 0 TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum % R PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ M TRANSFER FEE ■ S20.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr-- I S C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S ' 7 TOTAL DUE FOR OFFICE USE ONLY ................ ............. .............•...u•.u..�:��u::::::uvvvvvm 1 • ip' 'tl ' ltYt' SWEEPS (f COMPUTER 0_1 LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK VCASH EH 23 032 (REVISED 11-1-92) page 09 RECEIVED BY 2, DATE RECEIVED M TRANSFER FEE ■ S20.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr-- I S C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S ' 7 TOTAL DUE FOR OFFICE USE ONLY ................ ............. .............•...u•.u..�:��u::::::uvvvvvm 1 • ip' 'tl ' ltYt' SWEEPS (f COMPUTER 0_1 LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK VCASH EH 23 032 (REVISED 11-1-92) page 09 RECEIVED BY 2, DATE RECEIVED ' 7 TOTAL DUE FOR OFFICE USE ONLY ................ ............. .............•...u•.u..�:��u::::::uvvvvvm 1 • ip' 'tl ' ltYt' SWEEPS (f COMPUTER 0_1 LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK VCASH EH 23 032 (REVISED 11-1-92) page 09 RECEIVED BY 2, DATE RECEIVED