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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSI0M <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY T NAME <br /> I <br /> T <br /> E FACILITY ADDR SS SITE PHONE # with AREA CODE <br /> A <br /> CITY STATE ZIP CODE # of TANKS <br /> LP at SITE <br /> P APPLICANT/BILLIA 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 /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> A XXxx XXXX I XXXX I XXXX 1 $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicab(e) XXXX XXXX XXXX XXXX $ <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (muLtipty # by fee for <br /> A each year applicable) XXxX XXXX XXXX XXXX $ <br /> C L57e)6C <br /> I TANK PENALTY FEES ASSESSED XXXX I XXXX XXXX XXXX 5 <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Cade, Section 25287 <br /> T <br /> Y # Tanks Z x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> , $ <br /> LCPERMANENTCLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I 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) = $624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 878.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum 5 <br /> M I TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr 5 <br /> TOTAL DUE S -:;50"65J <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # I LOC CODE DIST CODEAMOUNT RECEIVED CHECK #/CASH RECEIVED BY I DATE RECEIVED _ <br /> I $ <br /> ���•��p� 3 <br />