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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> Sl FACILITY SITE NAME FACILITY CONTACT NAME <br /> T S <br /> E FACILITY ADDRESS u SITE PHONE # with AREA CODE <br /> a <br /> CITY c //` �� / STATE ZIP CODE # of TANKS <br /> A J W(..1L.�I.I/v at SITE <br /> P <br /> P APPLI T/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> TCITY 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 %XXX %XXX XXXX XxxX XXXX $ xxxxxxxxXXXX% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (i£ ApplicahLe) XX%XXXXX XXXX xxx% I XXXX S XXXX%%XXXX%XX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After JanuaryA <br /> J .� r <br /> E P <br /> # Tanks = �I 1986 1987 1988 1989 1990 1991 1992 1993 1994 <br /> F (multiply # by fee for A each year applicable) x%xx X%%x xxx% %xxx XXXX � Q �C I TANK PENALTY FEES ASSESSED %xxx XXXX X%%X %XXXXXXX <br /> L 1�1 ,C�1 r� <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 ��{'� Zk(If p l u "1-I D <br /> T <br /> Y # Tanks ?-/x 556.00 1988 through 1990 1991 through 1996 -7 VNA <br /> mo <br /> (Enter aunt and year) <br /> - 1'Z.' . <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 minimum/TANK) # TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 mini mm S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 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 5 <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(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) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = $234.00 minimum 5 <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> Si <br /> C CONSULTATION FEE = 578-00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE 5 L <br /> FOR OFFICE USE ONLY <br /> FA <br /> — <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED _ <br /> _......:......... ........ ... --..---._.._.._. ................. —_ __. —_.—_n_- __::-_— n._ _=__ :_:_ <br />