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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> UNDF" SOUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTIw./NAME <br /> 1 M, CQ S <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & �. <br /> CITY STATE ZIP CODE # of TANKS / <br /> A c9f SZo at SITE <br /> P <br /> PAPPLICANT/BILLING NAME APPL CANT CONTACT N ME <br /> 1 1( s � �� s <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> M l I O s . 7bN1 s- LEI <br /> T CITY STATE ZIP CODE / TYPE of APPLICATION U_37- QAM <br /> a It � � 3 �3b. (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> AXXXX xxxx xxxx xxxx xxxx S xxxxxxxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicab(e) %XXX xxxx XXXX xxxx XXxX S xxxxxxxxxxxxx <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks = t 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) xxxxxxxx xxxx xxxx <br /> C xxxx /7O X70 /70 /701 /70 /70 5 /0w <br /> I TANK PENALTY FEES ASSESSED XXXx xxxx XXXX <br /> L %X%X XXXX 70 7U X70 70 X7 (� Z,00 X70 5 O <br /> 1 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) I ��--yy <br /> � O <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK 1.0. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) # TANK(3)__L_ X $234.00 = S 3 <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) 5234.00 mini mm S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK 1.0. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) = 8234.00 mini mm S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = 878.00/hr S <br /> TOTAL DUE S Z 3 0(4` <br /> FOR OFFICE USE ONLY _ — 7, 'J <br /> .__..__._.._._............................_................... ._..._..._.._....._................___._.........-.._— <br /> SWEEPS # COMPUTER # I LOC CODE DIST CODE AMOUNT RECEIVED CHECK */CASH RECEIVED BY DATE RECEIVED - <br /> S <br />