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SAN JOAQUIN COUNTY —RUC HEALTH SERVICES - ENVIRONMENTAL HEALTP -IVS)ON <br /> UND6 1) STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT JVAME <br /> I <br /> T <br /> E FACILITY ADDRESS SITE HONE # with AREA CODE <br /> & 3 !4 y � - f6 o <br /> A CITY ZIP COOED atoSITENKS <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1 1988 1989 F1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) XXXX XXXX S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 4 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 J996 <br /> F (multiply # byby fee for <br /> A each year applicable) S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I <br /> R um TANK RETROFIT REPAIR FEE = 578.001hour (3 hours min./FACILITY) = $234.00 minim $ \ <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = $234.00 minimum S <br /> N TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr f ; Y <br /> I <br /> S G <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE .= 578.00/hr �,.L $ 7 , <br /> (J�,,,�Q,Ln TOTAL DUE z 0 <br /> FOR OFFICE USE ONLY <br /> ..__ _ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED ECK CASH RECEIVED BY DA RECFJ D <br /> f a $ 7 o - - <br /> EH 23 032 (REVISED 11-1.72) Page 11 <br /> �I <br />