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SAN JOAQUIN COUNTY `„LIC HEALTH SERVICES - ENVIRONMENTAL HEALTH , ,00iION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 _ <br /> T <br /> 'E FACILITY ADDRESS SITE PHONE At with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I d` S C\ Nq <br /> C MAILING ADDRESS PPLICANT PHONE # WITH AREA CODE <br /> M2. 0 5U Lv X20 1 SCDI 5 - Z <br /> T CITY STATE ZIP CODEAPPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5700.00 <br /> A XXXX xxxx xxxx XXXX %XXX 5 XXXx%XXx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx %xxx f XxxxxxxX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 9170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks = 1968 1989 1990 1 1991 1992 1993 1994 1995 11996 11997 1998 <br /> F (muttiply # by fee for <br /> A each year applicable) xxxx xxxx I xxxx I xxxx xxxx 9 <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx I xxxx I xxxx xxxx I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 s <br /> T <br /> T # Tanks_ x $8.00 1988 through 1993 (556) 1993 through 1997 ($56) 1998 <br /> SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxxxxxx s <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Plate) TANK E.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 478.00/hour (3 hours minimum/TANK) I # TANK($)_ X 6234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 678.00/hour (3 hours minimm/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review S Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 9 <br /> R REPAIR FEE (Workplan Review & Construction inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) _ X 5234.00 = f <br /> A <br /> I - TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) 4234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimmVFACILITY) _ $234.00 minimum S 01 <br /> , <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I s <br /> I <br /> S <br /> C CONSULTATION FEE = 978.00/hr SAMPLING INSPECTION FEE _ $78.00/hr I S <br /> TOTAL DUE f Uh <br /> FOR OFFICE USE ONLY _ <br /> a:— :r::r';::-„_ -,, � . :_.r <br /> J: E— -ED BYSAT <br /> SWEEPS # COMPUTER # LOC CODE -DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> m ' <br /> FM 74 ntJ (RFVISFD 1-12-98) <br />