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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> I FACILITY 5[T,E HA� I FA_C[LIr'f ?,TACT NAME <br /> T <br /> "E FACILITY ADDRESS /` SITE HON Ex vit AREA CODE <br /> i Cn%l/ R 7OP1 4, 14t <br /> A CITY � , /O C (� / S/TATE 2�[yPrCCDEof p at SITE KS / <br /> p T l �yV I yr lJ V <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> Cl MAILING ADDRESS APPLICANT PHONE X WITH AREA CODE <br /> Al <br /> N <br /> Tj CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 11988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A I XXXX ( XXXX )0= I XXXX I XXXX 5 XXXXXXXX <br /> C <br /> T1 FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX I XXXX XXXX I XXXX I XXXX ' S XX%XXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E <br /> k Tanks 1 1988 1989 11990 1991 11992 1 1993 11994 11995 ' 1996 11997 .' .a <br /> AI `achtyear �pplicable)r XXXX I XXXX XXXX XXXX IX]OO �x� I I7D I110I170 .��a ;1d 1-16 <br /> C <br /> 11 TANK PENALTY FEES ASSESSED XXXX XXxx XXXX 1 XXXX (XXXX xxyrl XXYI 110 1I TO I/70 KAb 1Q lD <br /> L <br /> f STATE SURCHARG'e FOR NEW FACILITIES ONLYi18.50 S 10 0=� <br /> T p <br /> TTanks_ X $8.00 1988 through 1993 (556) 1993 through 1997 (S56)LTQf I '1 <br /> 1 SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXx)D=XXX XXXX)=XXXXXXXXXXXXXXXX Il S 9��—o <br /> i <br /> CI IERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. :(s) <br /> L. <br /> al CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) I N TANK(s)_ _ X 1234.00 3 <br /> S' <br /> Ul TEMPORARY CLOSURE (Plan Review 3 Inspections) ( TANK I.O. +(s) <br /> Ri <br /> El TEMPORARY CLOSURE FEE - 378.00/hour (3 hours minimum/FACILITY) I $234.00 minimum 3 <br /> P1 INSTALLATION PLAN CHECK (Plan Review S Construction ?nspections)I TANK I.O. p(S) <br /> LI <br /> Al <br /> Al PLAN CHECK FEE = 578.00/hour (8 hours minimun/FACILITY) 3624.30 minimum 5 <br /> RI REPAIR FEE (Workplan Review 3 Construction Inspections) 1 TANK I.D. -'(s) <br /> E, <br /> P TANK L?KING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) N TANK(s) X $734.00 = 3 <br /> A <br /> 11 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 1234.00 minimus 15 <br /> R <br /> 1 PIPING REPAIR FEE = 578.00/hour (3 hours mininua/FALILITY) = 5234.00 minimum 3 <br /> Nj TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I 3 <br /> S <br /> C, CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 573.00/hr , 3 <br /> ' <br /> TOTAL DUE 5 I <br /> FOR OFFICE USE ONLY <br /> SWEEPS � CCMPUT'cR i LOC ,..,0E ' 0[ST CODE ! AMOUNT 3ECE?`IED '; CHECK './USH j RECEIVED 3Y ! DATE RECEIVED = <br />