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+ SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET S •T FACILITYSITENAME 1 FACILITY CONTAC NA 1987 1988 1989 1990 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK)/�� ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 'E FACILITY ADDRESS SITE PHONE # with AREA CODE # TANK(s) X $234.00 = U XXXX XXXX xxxx XXXX A CITY STATEJ ZIP CODE ,j # of TANKS at SITE P TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ P L, APPLICANT/BILLING NAME APPLICANT CONTATI; NAME 1 T FACILITY PENALTY FEES ASSESSED (If Applicable) C MAILING ADDRES�S� ( APPLICANT PHONE # WITH AREA CODE xxxx xxxx S XxXxxxxx T CITY h STA4 ZIP CODE TYPE of APPLICAI ON Installati V TANK FEE _ $50.00/TANK (Prior to January 1,1991) (Closufire, , etc.) TOTAL C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) 1986 1987 1988 1989 1990 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK)/�� ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 A N um PLAN CHECK FEE = $78.00/hour (8 hours minim/FACILITY) _ $624.00 minimum E O p # TANK(s) X $234.00 = U XXXX XXXX xxxx XXXX XXXX S XXXXXXXX A C TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum S T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx XXXX XXXX xxxx xxxx S XxXxxxxx V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 F (multiply # by fee for xxxx xxxx XXXX xxxx xxxx $ A each year applicable) C I TANK PENALTY FEES ASSESSED XXXX xxxx xxxx xxxx XXXX $ L I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 $ T Y # Tanks x $8.00 1988 through 1993 ($56) 1993 through 1997 ($56) 1998 SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxXxX xxxxxxxxxxxxxxxxxxxxxxx $ C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) L $ S 0 5 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK)/�� # TANK(s) i X $234.00 A N um PLAN CHECK FEE = $78.00/hour (8 hours minim/FACILITY) _ $624.00 minimum E O p # TANK(s) X $234.00 = U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L $ S A N um PLAN CHECK FEE = $78.00/hour (8 hours minim/FACILITY) _ $624.00 minimum E O p R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E $ S P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ A TOTAL DUE $ I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ R PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum S N I TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ S C CONSULTATION FEE = $78.00/hr SAMPLING INSPECT!0N FEE = $78.00/hr 5 TOTAL DUE $ FOR OFFICE USE ONLY SWEEPS # 1 COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/CASH I RECEIVED BY I DATE RECEIVED $ EH 23 032 (REVISED 1-12-98)