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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 1 FACILITY S ��o ? � FACILITY CONTACT NAME <br /> t <br /> T <br /> 'E FACILITY <br /> ADDRESS SITE PHONE % with AREA CODE <br /> C:TY C STATE ZIP CODE % of TANKS <br /> A at SITE 7--` <br /> P, <br /> P APPLICANT BILLING NAME <br /> � APPLICANT CONTACT MANE <br /> � <br /> I S -U.t� p t <br /> Al 'MA i1/N71-7/ ES^AOOJ1- AZ-o"' C �a I APPLICANT PHONE % 'JI iH AREA CODE <br /> M <br /> TI CITY STATE ZIP CyO�DE TYPE of APPLICATION <br /> f D! D 9%H -Z_ (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 11988 i 1989 l 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) - $100.00 <br /> A %XXX I xxxx I xxxx I XXXX i %XXX f XXXXXxxx <br /> C' <br /> T =ACUITY PENALTY FEES ASSESSED (!f Aoplicaml e) XXXX I XXXX xxxx I XXXX xxxx f XXXX%%x% <br /> t <br /> V DANK FEE = 350.00/TANK (Prior to January 1,1991) ( 5170/TANK (After January 1, 1991) <br /> E' <br /> 3 Tanks Z , 1988 1989 1990 1991 1992 1993 1994 i 1 11996 1199 1 1998 <br /> FI ',multiply % 'oy fee for <br /> Al each year applicable) xxxx xxxx xxxx I xxxx lxxxx 3L7f tv! p � yv j7 S20 'IL? <br /> C, <br /> II -ANK PENALTY FEES ASSESSED j XXXX XXXX XXXX xxxx !XXXX S7 �rJ Z.Z-/a 04, <br /> L <br /> II STATE SURCHARGE FOR NEW FACILITIES ONLY-S18.50 S �j f <br /> T' �! <br /> Y! % Tanks L/ x 38.00 1988 through 1993 (356) 1993 through 1997 (SS6)1 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXRXXXXXXXXXXXXXX %%XXXX%%%%%%XXXX%%XXXX% 1 flo-o7l S <br /> CI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.0. %(s) <br /> L' <br /> 01 CLOSURE FEE - 378.00/hour (3 hours minimMTANK) % LANK(s)_ X 52234.00 3 <br /> U TEMPORARY CLOSURE (Plan Review 3 Insoections) I TANK 1.0. %(s) <br /> R i <br /> Ej TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) 5234.00 minims 1 S <br /> P INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspections) TANK 1_0. %(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minims/FACILITY) = 5624.00 minims 5 <br /> RI REPAIR FEE (Workplan Review 3 Construction inspections) ` TANK I.D. %(s) <br /> E, <br /> PI TANK LINING REPAIR FEE = 578.00/hour (3 hours minims/TANK) % TANK(s) % 5234.00 = f <br /> A <br /> I; TANK .RETROFIT REPAIR FEE = 378-00/hour (3 hours min./FACILITY) _ $234.00 minims S <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minicAWFACILITY) c $234.00 minims f <br /> MI TRANSFER FEE = 520.00 I I UNAUTHORIZED RELEASE EVALUATION = x78.001hr I S <br /> 5 <br /> CI CONSULTATION FEE _ $78.00/hr I SAMPLING INSPECTION FEE _ $78.00/fir l i S <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONL7 l0—(o - <br /> -tr_:::-_._.:_:�--�=-- . ___,-_.____— -.--__ <br /> OMPU.__ C CODE--___-._.y____.R-.-_.__: 1 CHECK $/GSH RECEIVED 37 GATE RE�c?VE0 <br /> SWEEPS % COMPUTES % LOC CODE OIST CODE AMOUNT RECE.VED <br /> f <br /> =w 27 14P (PPVISF] 1-12-98) %NNW *mod <br />