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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br />RGROUND STORAGE TANK PROGRAM - FEE WORKSHEA& <br />S <br />FACILITY SITE NAME <br />FACILITY C n ACT NAM / <br />I <br />S ,lr _ _ <br />I i/ <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA C <br />S <br />% 2 0 <—:� <br />l <br />6::J 5i3 > 6 <br />& <br />CITY i S TATE <br />ZIP CODE <br /># of TANKS _ <br />A <br />'S,Y' <br />�S� Z <br />at SITE <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />R <br />P <br />PICANT/BILLING <br />NAME <br />yY$t <br />APP NT CONTACT NAME <br />L <br />' <br />/ cJ� C Ce�S <br />I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />N <br />T <br />CITY <br />TATE <br />ZIP COD <br />TYPE of APPLICATIOtF�� <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 I XXXX XXXX S 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 1 1987 1988 1989 1990 1991 1992 1993 1994 11995 1996 <br />F (multiply # by fee for <br />A each year applicable)XXXX XXXX XXXX XXXX XXXX S <br />C <br />I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX I XXXX XXXX S <br />L <br />I STATE SURCHARGE = 356.00 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 />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) <br />TANK I.D. #(s)�� <br />L <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s)--.:5— X 5234.00 = <br />S <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) _ $624.00 minimum <br />S <br />$ <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />R <br />El <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />TANK I.D. #(s) <br />L <br />E <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) _ $624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />$ <br />I <br />S <br />TRANSFER FEE = S20.00 I I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I I $ <br />CONSULTATION FEE = $78.00/hr I I SAMPLING INSPECTION FEE = $78.00/hr I I I S <br />TOTAL DUE I S <br />FOR OFFICE USE ONLY <br />