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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION F«j QSb3�J oZ <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 # with AREA CODE <br /> 8 30 <br /> CITY STATE ZIP CODE c # of TANKS <br /> A at SITE <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 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX s XXXXXXKXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX s XXXXXXXXXXXXX <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX s <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX s <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H B S Code, Section 25287 <br /> T <br /> Y N Tanks x 656.00 through 1490 4991__throm1996 <br /> (Enter amount and year) <br /> l(0 k 6, Is 3 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s)_ X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review A Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 678.00/hour (3 hours minimum/FACILITY) 6234.00 minimum S <br /> PAW" <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) m 1 <br /> L <br /> raS ED <br /> jonc <br /> N PLAN CHECK FEE - 578.00/hour (B hours minimum/FACILITY) $624.00 minimum .� N 6 J <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE - $78.00/hour (3 hours minimm/TANK) # TANK(s) X $234.00 = s <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 6 <br /> I <br /> S <br /> C CONSULTATION FEE = 678.00/hr SAMPLING INSPECTION FEE = 678.00/hr <br /> 1N -Oc20� JTAL DUE $ 33 f <br /> FOR OFFICE USE ONLY _ __ <br /> ._.._.._.._.. ........__ .__-_:::a::c............:::::_:_::::: :::�::::_:�:::..... ::_:::::::: ._......i.i.l 2F'P..:::v!2ii!!!!!!ii .... <br /> �::.. __..._..._._..._......cryo;•;;:......._:::::::_a: ..:...: .::::......................_.;c. --_ _ <br /> ..:::::::::::::!=a: rE CE!i:::::a�-_iiii:- <br /> a <br /> SWEEPS # {ONPUTE .LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> o: <br /> Ga 63 <br /> - —. ....£:s��.:.:'?:✓:::—?:-a9!iii!!isii!!::::a_::::-:a_:::::::-: <br />