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SAN JOAQU*NTY PUBLIC HEALTH SERVICES - ENVIRONMENTA�LTH DIVSION <br /> DERGROUND STORAGE TANK PROGRAM - FEE WORKS <br /> •FE <br /> FACILITY SITE NAME FAC LI TYON <br /> CTACT AME <br /> FACILITY ADDRESS SITE ONE # with AREA CODE <br /> & an S, r - D <br /> CI T,YSTATE ZIP CODE # of TANKS <br /> � <br /> A IA+ at SITE <br /> P <br /> P APPL, NT/BILLING NAME APPLICANT CONTACT NAME <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 /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX E XXXXXXXX <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1 1988 1989 1990 1991 1992 1993 1 1994 1995 1996 1 1997 199 Wrp5050 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX ' Q $ do <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 $ <br /> T <br /> Y # Tanks _ x $8.00 1988 through 1993 (S56) 1993 through 1997 (856) 1998 <br /> SURCHARGE FOR 1998 XXXX%XXXX%XXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = 5 <br /> A <br /> TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr 5 <br /> i <br /> 5 <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> .............................................................................._....................................... ................................_.............._....................._......................................I............................ <br /> :::::_-_::--:-:::::::_::::!:::::;::::::::::::::::!:::::: rs::�:::: ::::::::::i::=.:::::::;::::::::::::: ::::!:::_:::::::::_:::::::__�::::::::::-:::::::::::::::�:: :::: -::::::::::,::::: ::::::::::.::::::::::::::::::::::-:.:::,::::::iz:mmmn :itit <br /> :::: <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> 5 ... <br /> ii............_._._...::::::::.....:.::-:...,.........._.._....,::::..--........................._.....__...........__..._. :............................._._............ ................................_....._._.........._.........:..._............ ........................ <br /> .....:-..... .. _._ - .................... .. <br /> Ih::::::::::�:::::::::::::::::::::�:::::�:�::::::::!ii:::::�__..::_::_::::::::::�e:_::::!icui!__.:_:::::_:_!:::�:__._!::::::::::::::::::::::�::::::::::::i::_:::::!!::::::::::::::::::::::� :......: :::_::::::�::::::::::::::::.-.::.:::.::::::..::::::::::::................................................ <br /> EH 23 032 (REVISED 1-12-98) <br />