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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - EMVIRoNMENTA6WLTH OIVSION <br /> ERGROUNO STORAGE TANK PROGRAM - FEE WORKS <br /> S FACILITY SITE NAME 11 <br /> I FACILITY CONTACT N E <br /> T 9 <br /> E FACILITY ADDRESS zQ�.� <br /> D SI E PHONE 4' With AREA CODE <br /> & , C ? <br /> A <br /> CITY V�0 G C gE Z CODE OD T # of TANKS <br /> P U at SITE <br /> P APPLICANT/BILLING NAME <br /> I �. � APPLICANT CONTACT NAME <br /> C MAILING ADDRESS <br /> A li APPLICANT PHONE # WITH AREA CODE <br /> N <br /> T CITY <br /> /( STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> A ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 1986 1987 1988 1989 1990 <br /> C XXXX XXXX XXXX XXXX XXXX $ xxxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I xxxx xxxx xxxx xxxx xxxx $ XX%XXXXX <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br /> E $170/TANK (After January 1, 1991) <br /> # Tanks = 1987 1988 1989 1990 1991 1992 11993 1994 1995 1996 1997 <br /> F (multiply #by fee for <br /> A each year applicable) XXX% XXXX XXxX I XXXX jxxxx <br /> 178 $ <br /> [ TANK PENALTY FEES ASSESSED XXXX XXXX XX%X XXXX %XXX <br /> L $ <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = 518.50 <br /> T <br /> Y # Tanks_ x $8.00 1988 through 1990 ($56) 1991 through 1996 (S56) 1997 / <br /> SURCHARGE FOR 1997 XXXXxxXXXXXXXXXXXXXXXXxxxxx Xxxxxxxxxxxxxxxx%Xx%xxx B'O <br /> S d D <br /> C PERMANENT CLOSURE (Removal-or Authorized Closure-in-Ptace) <br /> L TANK LD. #(s) O <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /> S # TANK(s)__ X $234.00 = $ <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R TANK I.D. #(a) <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minim u/FACILITY) $234.00 minimum <br /> $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) <br /> _ $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) <br /> E TANK I.D. #(s) <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 g <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum R $ <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimm/FACILITY) = $234.00 minimum <br /> 8 <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br /> I $ <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE <br /> = $78.00/hr S <br /> TOTAL DUE $ CO <br /> FOR OFFICE USE ONLY .J <br /> €: . <br /> CODE AMOUNT RECEIVED (NECK #/USN RECEIVED BY DATE RECEIVED <br /> S [t <br /> EN Z3 032 (REVISED 5-27-97) <br />