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SAN JOAQUIN �TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL SIH OIVSION <br /> ERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FALILI Y SITE NAME <br /> I FACILITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY 1 L �� STA E ZIP CODE # of TANKS <br /> A C q��ba at SITE <br /> P <br /> P APPLICANT/BILLING NAME <br /> L APPLICANT CONTACT NAME <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 19861987 1988 1989 1990 <br /> A <br /> C XXX% XXXX I XXXX XXXX XXXX S XXXXX%%X <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X%X% <br /> 1 XX%X XXXX XXXX XXXX S XXXXXXXX <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) yI/f <br /> E <br /> # Tanks = 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XX%X X%XX XX%% 7p l?D l 7D 7Q1'768 n <br /> C <br /> LTANK PENALTY FEES ASSESSED XXX% %XXX %XXX XXXX XXXX –7d ' I –l0 S oa <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 I5 _ <br /> T <br /> Y # Tanks x $8.00 1988 through 1990 ($56) 1991 through 1996 ($56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXX%%XX XXXXX%XXX%XXXXXXX%XXXXXMUM Tr n44QEC <br /> C PERMANENT CLOSURE (RemovaL or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = g <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) <br /> R TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum g <br /> P INSTALLATION PLAN CHECK (PLan Review 8 Construction Inspections) TANK 1.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 878.00/hour (8 hours minimum/FACILITY) = $624.00 minimum g <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 8234.00 = g <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum g <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) S234.00 minimum g <br /> M TRANSFER FEE = 820.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr g <br /> I <br /> 5 <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr I g <br /> TOTAL DUE $ a 6 <br /> FOR OFFICE USE ONLY <br /> I - <br /> mat <br /> SWEEPS # I COMPUTER # I LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY <br /> DATE RECEIVED <br /> S <br /> ____ .. ....._... <br /> siiit=i' .=.ii' ii9[_`-i=-':=.ii__i_-- _[_:-`_'__r-=_ -i- `- t =":= ["?u .':;r-5't[ =_'-munn:i' iiiiii ;_iii- <br /> EH 23 032 (REVISED 5-27-97) <br />