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SAN JOAOUIN COU[' oUBLIC HEALTH SERVICES - ENVIRONMENTAL HEA1T° DIVISION
<br />UNDER AD STORAGE TANK PROGRAM - FEE WORKSHEET
<br />S
<br />FACILITY SITE NAME /
<br />FACILITY CONTACT NAME
<br />T
<br />1988
<br />1989
<br />1990
<br />0
<br />A
<br />E
<br />FACILITY ADDRESS
<br />SITE PHONE # with AREA CODE
<br />XXXX
<br />'3
<br />XXXX
<br />&
<br />C
<br />T
<br />FACILITY PENALTY FEES ASSESSED (If Applicable)
<br />XXXX
<br />xxxx
<br />XXXX
<br />CITY
<br />STATE
<br />ZIP CODE
<br /># of TANKS
<br />P/
<br />$234.00 minimum
<br />S
<br />�CzO f;
<br />at SITE
<br />I
<br />V
<br />P
<br />APPLICANT/BILLING NAME
<br />APPLICANT CONTACT NAME
<br />L
<br />E
<br /># Tanks =
<br />1
<br />C
<br />MAILING ADDRESS
<br />APPLICANT PHONE # WITH AREA CODE
<br />A
<br />1990
<br />1991
<br />N
<br />1993
<br />1994
<br />1995
<br />1996
<br />T
<br />CITY
<br />STATE
<br />ZIP CODE
<br />TYPE of APPLICATION
<br />XXXX
<br />XXXX
<br />xxxx
<br />(Closure, Installation, etc.)
<br />TOTAL
<br />C
<br />PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace)
<br />1986
<br />1987
<br />1988
<br />1989
<br />1990
<br />0
<br />A
<br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00
<br />XXXX
<br />XXXX
<br />XXXX
<br />XXXx
<br />XXXX
<br />S xxxxxxxXXXXXX
<br />C
<br />T
<br />FACILITY PENALTY FEES ASSESSED (If Applicable)
<br />XXXX
<br />xxxx
<br />XXXX
<br />XXXX
<br />XXXX
<br />S XxXXXXXXXXXXX
<br />R
<br />E
<br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY)
<br />$234.00 minimum
<br />S
<br />I
<br />V
<br />TANK FEE = 550.00/TANK (Prior to January 1,1991)
<br />S170/TANK (After January 1, 1991)
<br />E
<br /># Tanks =
<br />1986
<br />1987
<br />1988
<br />1989
<br />1990
<br />1991
<br />1992
<br />1993
<br />1994
<br />1995
<br />1996
<br />F
<br />A
<br />(multiply # by fee for
<br />each year applicable)
<br />XXXX
<br />XXXX
<br />XXXX
<br />XXXX
<br />xxxx
<br />S
<br />C
<br />I
<br />TANK PENALTY FEES ASSESSED
<br />XXXX
<br />XXXX
<br />XXXx
<br />xxxx
<br />xxxx
<br />$
<br />L
<br />I
<br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287
<br />T
<br />Y
<br /># Tanks x $56.00
<br />1988 through 1990
<br />1991 through 1996
<br />(Enter amount and year)
<br />S
<br />C
<br />PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace)
<br />TANK I.D. #(s)
<br />L
<br />,:::::•::::::::::::::::::::::::::::::::::::::::::::::,:::::::::,::::::::::::::::::::::::,..::::::.:....,.,....:..:;:........,
<br />.......................................................
<br />SWEEPS #
<br />L
<br />0
<br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK)
<br /># TANK(s) X 5234.00
<br />-7 0. 0
<br />5
<br />S...r..:;.. ' C.
<br />S
<br />A
<br />I
<br />S
<br />S
<br />SAMPLING INSPECTION FEE = 578.00/hr
<br />U
<br />TEMPORARY CLOSURE (Plan Review & Inspections)
<br />TANK I.D. #(s)
<br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum
<br />S
<br />R
<br />E
<br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY)
<br />$234.00 minimum
<br />S
<br />P
<br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)
<br />TANK I.D. #(s)
<br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr
<br />,:::::•::::::::::::::::::::::::::::::::::::::::::::::,:::::::::,::::::::::::::::::::::::,..::::::.:....,.,....:..:;:........,
<br />.......................................................
<br />SWEEPS #
<br />L
<br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK)
<br /># TANK(s) X S234.00 =
<br />A
<br />N
<br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum
<br />5
<br />R
<br />REPAIR FEE (Workplan Review & Construction Inspections)
<br />TANK I.D. #(s)
<br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr
<br />,:::::•::::::::::::::::::::::::::::::::::::::::::::::,:::::::::,::::::::::::::::::::::::,..::::::.:....,.,....:..:;:........,
<br />.......................................................
<br />SWEEPS #
<br />E
<br />P
<br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK)
<br /># TANK(s) X S234.00 =
<br />S
<br />li
<br />S...r..:;.. ' C.
<br />S
<br />A
<br />I
<br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum
<br />S
<br />SAMPLING INSPECTION FEE = 578.00/hr
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<br />R
<br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum
<br />S
<br />M
<br />TRANSFER FEE = $20.00
<br />::..,......-:..
<br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr
<br />,:::::•::::::::::::::::::::::::::::::::::::::::::::::,:::::::::,::::::::::::::::::::::::,..::::::.:....,.,....:..:;:........,
<br />.......................................................
<br />SWEEPS #
<br />S
<br />I
<br />.......:..:....:iil??:isii::::::::::::::::::::::::::...........i................:.......:»....n........._......:.........................:.,...,.:l,...:
<br />CHECK #/CASH
<br />RECEIVED BY DATE RECEIVED ;
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<br />li
<br />S...r..:;.. ' C.
<br />S
<br />S
<br />C
<br />CONSULTATION FEE = 578.00/hr
<br />...............................................................................................................................:3._...:....................:....................................................................._...9..
<br />•::• ::••::� ::.. ,..,. .... .......... :....................... .... ,........
<br />SAMPLING INSPECTION FEE = 578.00/hr
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<br />$
<br />TOTAL DUE
<br />S t 70. CO
<br />FnR OFFTrF USF ONLY
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<br />,:::::•::::::::::::::::::::::::::::::::::::::::::::::,:::::::::,::::::::::::::::::::::::,..::::::.:....,.,....:..:;:........,
<br />.......................................................
<br />SWEEPS #
<br />... ..«:r....................................r.........................................................:........
<br />COMPUTER # LOC CODE DIST CODE
<br />.....
<br />AMOUNT RECEIVED
<br />.......:..:....:iil??:isii::::::::::::::::::::::::::...........i................:.......:»....n........._......:.........................:.,...,.:l,...:
<br />CHECK #/CASH
<br />RECEIVED BY DATE RECEIVED ;
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