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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> V 2GR0UND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE FACILITY COATI(CT NAME <br /> T <br /> E FA CIL TY_AOORESS ^� SITE HONE # with AREA CODE <br /> 397 <br /> CITY STATE ZIP CODE # of TANKS <br /> A `Ii--Q a 6,5 at SI <br /> TEI <br /> P <br /> P APPLICANT/BILLING AME APPLICANT CONTACT NAME <br /> —Gi r. <br /> C MAILING ADDRESSye-� APPLICANT PHONE # WITH AREA CODE <br /> A Cbl <br /> N ' (y- <br /> T CITY <br /> S_ S TYPE of at(Closure, Installion, etc.) <br /> O [J b <br /> 16TAL I <br /> 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 <br /> A XXXx XXXX XXXx XXX% XXXx S XX%XXXXXXX%%% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XX%X xxxx I X%XX XxxX S XXXx%%%XX%XXX <br /> I £f <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) 06(6[ <br /> E <br /> # Tanks = 19861987 1988 1989 1990 1991 1992 1993 1994 1 1995 1 1996 <br /> F (multiply # by fee for <br /> A each year applicable) %XXX XXXX XXXX xXxx XXXX <br /> C 170 <br /> V <br /> I TANK PENALTY FEES ASSESSED %%XX XXXX XXXX XXxx XXXx S <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x S56.001988 through 1990 1991 through 1996 SNJSF 071 ;l(q <br /> (Enter amount and year) <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 5734.00 = 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 minimm/FACILITY) 5234.00 minimum a <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 minimuNFACILITY) = 2624.00 minimum $ <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK 1.0. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 mini muin S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 278.00/hr S <br /> TOTAL DUE S �� 0 <br /> FOR OFFICE USE ONLY <br /> ............._..._._:. ___.._._......_._........_..._...__......._.__.____... <br /> y SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> si <br /> - S - <br /> .�.=�.Ti <br />