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: <br /> SAN JOAQUIN COUN BLIC HEALTH SERVICES - ENVIRONMENTAL HEALOVSIOM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITEME FACILITY CONTACT NAME <br /> I lA� S,� lMIK2 r-E� s <br /> T <br /> 'E FACILITY ADDRESS SITE PHONE A with AREA CODE <br /> CITY STATE ZIP CODE X of TANKS <br /> FS'TJ ` 2�ZlI at SITE /..L`K (/L Y1tY✓c:.`,� <br /> APPLICANT/B LING NAME / APgqPL�ICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE : WITH AREA CODE <br /> A <br /> T C TY } ` STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, InstaLlation, etc.) <br /> TOTAL <br /> 1986 11987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A XXXX I X%X% XXX% XX%% XXXX S XX%XXXXX <br /> C' <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXx I Xxxx XXXX I XXXX Xxxx S %%%XXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E <br /> d Tanks = 1988 1989 1 1990 j 1991 1992 1993 11994 1995 11996 1997 1998 <br /> (multipLy T—by fee <br /> r <br /> AI each year applicable) xxxX I XXXX ! X%%X XXXX XXxx I 13 <br /> ITANK PENALTY FEES ASSESSED I XXXX I XXXX XXXX %XXX Ixxxx I I 13 <br /> L <br /> 1 STATE SURCHARGE FOR NEW FACILITIES ONLY=418.50 3 <br /> T1 <br /> I Tanks_ x 58.00 1988 through 1993 (556) T <br /> 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 xxxxxxxxxxxxxxx%xxxxxxxXXXX XXXX%xxxxxxxXXx%%%xxxxX S <br /> Cl 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) I a` iANK(s)_ X $234.00 = i S <br /> S <br /> Uj TEMPORARY CLOSURE (P(an Review 8 Inspections) TANK 1.0. AS) <br /> R <br /> EI TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 mini mum S <br /> PI INSTALLATION PLAN CHECK (Plan Review 3 Construction inspections)i TANK I.D. As) <br /> L <br /> A <br /> N PLAN CHECK FEE= = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br /> R REPAIR FEE (Workplan Review 3 Construction Inspections) TANK I.D. 3(s) <br /> E <br /> l I <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) TANK(s) _ X 5234.00 = S <br /> A <br /> 11 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minima S <br /> M TRANSFER FEE = $20.00 I I UNAUTHORIZED RELEASEE EVALUATION = S78.00/hr I I S <br /> I <br /> 5 <br /> C CONSULTATION FEE S78.00/hr I SAMPLING INSPECTION FEE = S78.00/hr I S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS d COMPUTER 4 LOC CODE ' DIST CODE AMOUNT RECEIVED ( CHECK :/CASH I RECEIVED BY I DATE RECEIVED <br /> i <br /> EH 23 032 (REVISED 1-12-98) <br />