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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET S FACILITY SITE NAME FACILITY CO ACT ME I T 'E FACILITY ADDRESS SITE PHONE # With AREA CODE a 1�o-t A CITY ^�0 C STATE ZIP CODE aN oft SITE TANKS P J P APPLICAN /BILLING NAME _ APPLICANT CONTACT NAME L I C MAILING ADDRESS _ APPLICANT PHONE # WITH AREA CODE A , N. N T CITYr G STATE ZIP COD TYPE of APPLICATION baG �1 ld (Closure, Installation, etc.) r TOTAL 1986 1987 1988 1989 1990 ANNUAL FACILITY FEE (Prior to January 1, 7991) = $100.00 A XXXX XXXX XXXX XXXX XXXX S XXXXXxxx C T FACILITY PENALTY FEES ASSESSED (If Applicable) XX)X xxxx XXXX xxxx XXXX S xxxxxxxx 1 V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # tanks = 1988 7989 1990 1991 1992 1993 7994 1995 1996 I19W97C" F F (multiply # by fee for A each year applicable) xxxx xxxx xxxx xxxx xxxx xxy y-yX , � 'rD CI TANK PENALTY FEES ASSESSED xxxx XXX% XXXX XXXX XXXX }(X11 (V D+L I STATE SURCHARGE FOR NEW FACILITIES ONLY=Sib-50. ` (�, a T Y # Tanks_ x 58.00 1988 through 1993 (S56) 1993 througK 1997 ($56) ®80 SURCHARGE FOR 1998 xxxxxxxxxxxxxxXXXXXXxxxXXXX XXxxxxxxxxxxxxxxxxxxxxx q,V 5 C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) LOI 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)__I_ X $234.00 = S 5 U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum S P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum $ R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ x 5234.00 = S A I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S R PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr f I S C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S TOTAL DUE S .FOR OFFICE USE ONLY ..._....... .-.......................... ................-___—.... .._.. .........::::::._::::::.r...T - ______ _ .................._......__..._..........................................................._..._._....._.._._._..........::..-..-......_..........__.._._......_...__.............. ............... ..._.........._.__:_tt_.:.::.— __-_ - - ................_....__............................................................................._........_._........._._._..............._................._..._....._..._. �:nn.:::::.....,.. :...�.�.._..__.; �i.LL _ - ' - ' _ :- ......_......._......._....................................................................................._............._...._.._............. r_......................... ...__.. ..__ :._......__.:.__..._....__.._.............................................._.._.._.__........__.__..........:: _.._...... ....... ..._.._.::.....::::::�.:::::.n_.::_... .:n_:::=:_. _.. _ _.....::_:-..—_.n.. _:: :::i: SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED aw am-19 $ _......................_._.._ .....s ... :..::e:......:.....................n...:z....n_.rt_........s__n..._...._.................._... ._e..............__...... ma :......._c:.._:::........_.......... ......_._.._..........:c:::o::.—::z:........ :::::ee::::-��:::::-�_..:::o::::�::::::�::::::::::::�:::...:.__.:::::_-:-_.�:::__..:...::�::::::::::::::n:::: :::c=::�::;.:::::_: !�::-::�::::::::::::::!!!:11m::.-i!::::::��—::::::::e:-:::::� :--_n:::::--5�__ EH 23 032 (REVISED 1-12-98) lX+ 1 �,.1, T� `moi a�' I �V ' v" brl`&