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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION _ <br /> I' RGROUND STORAGE TANK PROGRAM - FEE WORKSHEr_. <br /> S FACILITY SITE NAME FACILITY CUm,ACT NAME <br /> I <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY , �,( JIPC7ODDE # of TANKS <br /> P ' ' - �,-STATE� <br /> � at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <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 /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) + <br /> L <br /> " N1 AY <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum s <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) HEALTH SERV1(,:i_., <br /> E - <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $, <br /> I <br /> S -- <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE $ " OG' <br /> l�'4n1 r Ski, <br /> FOR OFFICE USE ONLY <br /> .................................................................... <br /> N. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIV K, /CASH RECEIVED BY DATE RECEIVED <br /> $ <br /> C� <br /> :::........................................ ........................... r(::::::::::: .:: :•::::::.::::::::::::::::::::::::::::::::::: <br /> s:::s ::::::::::::::::::::::::::::s:::::::: :::::::::::;;::s:::::::::i i €i€iii 'i€€;is................... ': ':i's':€;: :::;€€€€i€iiitsii €; €'s€iii _ ...........................................f . 1 ..: =:; .. <br />