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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSIOY <br /> UNOF 'XRM) STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILLTY CCNTACT NAME <br /> I co1 L <br /> T <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & p , <br /> A a CITY CD""7"CI STATE IP CODE of TANKS <br /> N at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C NAILING ADDRESS APPLICANT PHONE * WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, [nsiaLLacimn, em.) <br /> TOTAL <br /> 1986 1987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX I %XXX I XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1988 11989 1990 1991 1992 11993 1994 1995 1996 1997 11998 <br /> F (muLtiply # by fee for <br /> A each year app(icable) XXXX I XXXX %XXX XXXX (XXXX I I I S <br /> G <br /> I TANK IXXX I I %XXX IXXXX I i I <br /> PENALTY FEES ASSESSED X %XXX XXXX S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 5 <br /> T <br /> Y # Tanks , z 58.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX , S <br /> CI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK LD. #(S) <br /> Li I + <br /> 0� CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s)_;___ % S254.00 = S IU <br /> 5 <br /> UI TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.J. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 1234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review 3 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 /> RI .REPAIR FEE (Workplan Review g Construction Inspections) I TANK 1_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) SZ34.00 minima S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I <br /> S' <br /> L CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.001hr I i <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> MSWEEPS # COMPUTER % `LOC CODE DIST CODE AMOUNT RECEIVED CHECK */CASH I RECEIVED By DATE RECEIVED <br /> g I S <br /> EH 23 032 (REVISED 1-12-98) <br /> v `� <br />