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SAN JOAQUIN COUNTY tUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH ..iVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I _ � <br /> T <br /> 'E FACILITY ADDRESS SITE PHONE x with AREA CODE <br /> CITY STATE ZIP CODE x of TANKS <br /> A at SITE <br /> P _ <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I —\ t+- S C\ � \ S N \ > pl, —t— <br /> C MAILING ADDRESS PPLICANT PHONE $ WITH AREA CODE <br /> wr�vx <br /> C4 S - Z <br /> T STATE ZIP CODE APPLICATION <br /> N 1: N �� 4 2 (Closure, Installation, etc.) <br /> I� TOTAL <br /> 1986 1987 11988 i 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX I XXXX XXXX XXXX S xXXXXxXx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX I XXXX XXXX XXXX S xxxxxxxx <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> E <br /> I Tanks = 1988 1989 1990 1 1991 11992 1993 1994 11995 11996 1997 11998 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx XXXX ( XXXX 1 XXXX XXXX I S <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXxx XXXX I XXXX I XXXX (XXXX I I I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 S <br /> T <br /> Y I Tanks x $8.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXxxxxxxxXxxxxxxxXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Remova( or Authorized Closure-in-Place) TANK I.O. s(s) <br /> L <br /> 01 CLOSURE FEE _ $78.00/hour (3 hours minimun/TANK) # TANK(s) X 5234.00 = S <br /> Si <br /> UTEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. x(s) <br /> EI TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections)I TANK I.O. 4(s) <br /> Ll <br /> A <br /> NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. x(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I 0 TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) _ $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S U <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I S <br /> I 1 <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S vI <br /> T <br /> FOR OFFICE USE ONLY <br /> __.... ....._:..._......__._.................___ .... ..- --_:._.___. .._— _ _.... _ ...... <br /> SWEEPS COMPUTER I I LOC CODE I DIST CODE I AMOUNT RECEIVED 1 CHECK I/CASH I RECEIVED BY I DATE RECEIVED <br /> S <br /> .. t <br /> (RFVTSF0 1-12-98) <br />