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SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSIOM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> "E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> i <br /> CITY ESTATEEZIP CODE # of TANKS <br /> A I at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 7986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX XXXX %XXX X%%X S XX%XXX%% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (]f AppLiwble) XXXXXXXX xX%X XX%X %XXX f XXX%%XX% <br /> I <br /> V TANK FEE • 550.00/TANK (Prior to January 1,7991) (170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 7990 1991 11992 1 1993 7994 1995 11996 11997 1998 <br /> F (multiply # by tee for <br /> A each year applicable) XXX% %XXX I XXXX XXXX X%X% S <br /> I TANK PENALTY FEES ASSESSED I XXXX XXX% X%X% XXXX (XXXX I I I I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=S18.50 S <br /> T <br /> T # Tanks x $8.00 1988 through 1993 (556) 7993 through 1997 (556) 1998 <br /> SURCHARGE FOR 1998 XX%XXXXxxxxxxxXXXXX%XXX%XXX %XXX%%XXXXXXXXX%XXX)(%XX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = (78.00/hour (3 hours minimm/TANK) I # TANK(s) X 5234.00 : f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - S78.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br /> S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(5) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br /> S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) It TANK(s) _ X 5234.00 = { S <br /> A <br /> I - TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> N TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I <br /> S <br /> C1 CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE - S78.00/hr 5 <br /> TOTAL DUE ' S <br /> FOR OFFICE USE ONLY _ <br /> .:_ _ :�_.-".... -8_a_—m_—;;__ ... ._:�`-�:�- _. ..___:_ <br /> _...__. _ _ _ _ _.. _._. __...____.._::-.:-:::_. _ ___ _ -_ <br /> SWEEPS # COMPUTER Al LOC CODE DISI CODE AMOUNT RECEIVED �__- ���— <br /> ._.�. . . -^_._ ...� _ _ _ _tea`-��z:z :._..___— <br /> I� CHECK #/GSH RECEIVED ar DATE RECEIVED - <br /> Rw Pi n2J IRFVISFD 1.12-98) <br />