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SAN JOAQUIN COUNTT PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALIn.:_VSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> 'E FACILITY ADDRESS SITE PHONE 9 with AREA CODE <br /> & <br /> CITY I STATE ZIP CODE N of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MMI IN-G ADDRESS APPt1CANT-PHONE-;* WITH—AREA-CODE — <br /> A <br /> N <br /> T CITY STATE ZIP CODE I TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> F1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00A XX XXXX I XXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX XXXX XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> I Tanks = 1988 1989 1990 1991 11992 1993 1 1994 1995 11996 11997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX I I S <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX XXXX I XXXX (XXXX I f I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T IY # Tanks x $8.00 1988 through 1993 CS56) 1993 through 1997 (556) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.O. S(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) I 9 TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. A(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimus S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. ;*(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. 0(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) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I I I 1 <br /> S <br /> C CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = S78.00/hr I S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK $/CASH RECEIVED BY DATE RECEIVED <br /> PW 21 nip (RFVISFO 1-12-98) <br />