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• SAN JOAOUIN C(.1NTY Pt18L1C HEALTH SERVICES - ENVIRONMENTAL IIEAL*DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I SP <br /> 1 E FACILITY ADDRESS SITE PHONE ht with AREA CODE <br /> 6 <br /> Cl STATE ZIP CODE # of TANKS <br /> A > o� /• ��� at SITE <br /> P 7 <br /> P#APPLICANT/GILLING NAME APPLI NT CONTACT NAME <br /> I <br /> CSSAPPLICANT PHONE # UITHAREA CODE <br /> Aso �T Z TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> 1� TOTAL <br /> 1906 19II7 1988 7989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A Xxxx xxxx 5 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I xXXx XXXX $ <br /> V TANK FEE = $50.00/TANK ;^ris,� to-January 7,1997) ;170/TANK (After January 1, 7991) <br /> E <br /> 0 Tanks = 1906 7987 7988 1989 1990 . 1991 11992 1993 1994 1995 7996 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx Xxxx E <br /> C <br /> 1 TANK PENALTY FEES ASSESSED xxXx xxxx E <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> ., (Enter amount and year <br /> �\ $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FH- S78.00/hour (3 hours minimum/TANK) <br /> ;f TANK(s) X $234.00 = E <br /> S <br /> U TEMPORARYPlan Review S Inspections) TANK <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) $234.00 minimum E <br /> P INSTALLATION PLAN CHECK (Plan Review 3 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 E <br /> R REPAIR FEE (Workplan Review 8 C'ons"truction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours mini mum TANK) # TANK(s) _ X $234.00 = $ <br /> A <br /> 1 TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) = $234.00 mini mum E <br /> R <br /> PIPING REPAIR IEE _ $78.00/hour (3 hours mini mum/FACLLITY) _ $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S y <br /> C CONSULTATION FEE _ $78.00/hr "I SAMPLING INSPECTION FEE 178.00/hr <br /> TOTAL DUE E z?3 q <br /> M. <br /> )R OFFICE USE ONLY <br /> SWEEPS 1# I COMPUTER 9 LOC CODE DIST CODE AMOUNT RECEIVED I CHECK ../CASH RECEIVED BY DATE RECEIVED <br />