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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION 11V V 72/ly <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 1 FACTLL1Y1 S0 �AM� <br /> E FACILl FACILITY CONTACT NAME <br /> TY ADDRESS / SITE PHONE k with AREA CODE <br /> A CITY, ZIP r ^7g7E 2TP E r- a of TANKS <br /> P � Ci i SITE <br /> PAPPL ANT/ LLING NAME PPLICANT CON CT NAME _ <br /> C MAILING A KESS APPLICANT PHONE ! WITH AREA CODE <br /> A <br /> N <br /> T CITSTAIE ZIP CODE TY PLICATION <br /> / 5 Closure,.'I nstaltatio, etc.) <br /> TOTAL <br /> 1986 11987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 -/ <br /> A XXXX XXXX /. / S �iO� QS <br /> C qq <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX / '�I s Soo <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> Y Tanks = 1986 1987 1988 1989 11990 1 1991 11992 1993 1994 1995 1996 <br /> F (multiply 4 by fee for /_ <br /> A each year app(icable) XXXX Xan _d - ? S Lf' ( G �jOJ <br /> ILSI —o a 1 0 9 � <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX <br /> S 1 <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> YI $ Tanks_ x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. z(s) <br /> L <br /> 0 CLOSURE FEE - 278.00/hour (3 hours minimum/TANK) 3 TANK(s)_ X 5234.00 = s <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK 1_0. F(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/FACILITY) 3234.00 minimum S <br /> PINSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. 3(s) <br /> L <br /> A <br /> NJ PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br /> f <br /> R REPAIR FEE (Workplan Review & Construction Inspectiotu) TANK 1.0. x(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimID/TANK) B TANK(s) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimm S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minimum I <br /> NJ TRANSFER FEE = SZO.00 UNAUTHORIZED RELEASE EVALUATION - s78.00/hr 2 <br /> I <br /> S <br /> Cl CONSULTATION FEE 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr f <br /> TOTAL DUE s <br /> FCR OFFICE USE ONLY _ <br /> DIST CODE <br /> SWEEPS I COMPUTER 4 L7 -ODE DIST RECEIVED CHECK d/CASH RECEIVED 3Y DATE RECEIVED <br /> S <br /> cH 23 032 (REVISED 10-28-93) Paye 11 <br />