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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> -RGROUND STORAGE TANK PROGRAM - FEE WORKSHF` <br /> SIFACILITY SITE NAME / FACILITY L.—ACT NAM / <br /> T i <br /> E FACILITY ADDRESS SITE PHONE with AREA C <br /> CITY <br /> 1,,�kATE� ZIP CODE of TANKS _ <br /> A <br /> at SITE <br /> P <br /> P A ICANT/BILLING NAME APP, ' NTJ CONTAC/T NAME <br /> IC� v <br /> C MAILING ADDRESS �� / u APPLICANT PHONE $ IJIT4 AREA CODE <br /> A > > 5 7? i {✓ O! <br /> T CITY 7E ZIP COO'-E- TYPE of APPLiCATIClS— <br /> (CLasure, Insta(Lation, etc.) J �(� <br /> cvT� T TOTAL <br /> 1986 I 1987 i 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX I XXXX XXXX I XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX I XXXX I XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 4 Tanks = 1986 1987 1988 11989 11990 1991 1992 1993 11994 11995 1996 <br /> F (multiply I by fee =or <br /> A each year applicable) XXXX I XXXX I XXXX I XXXX XXXX I S <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX I XXXX XXXX I XXXX I XXXX I i I S <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y X Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> Cl PERMANENT CLOSURE (Removal or Authorized CLosure-in-P(ace) I TANK I.J. 4(s) <br /> OIL TANK(s) X 5234.00 = S <br /> CLOSURE FEE = 178.00/hour (3 hours minimum/TANK) V <br /> S <br /> U TEMPORARY CLOSURE (P(an Review & Inspections) I TANK I.D. 9(s) <br /> Rl — <br /> EI TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (P(an Review & Construction Inspections)j TANK I.O. ;*(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 3624.00 minimum S <br /> R, REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. 0(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) $ TANK(s) X 5734.00 = 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 minimum S <br /> N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I I I I <br /> S <br /> C CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = $78.00/hr I I S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS 9 COMPUTER LOC CODE DIST CODE I AMOUNT RECEIVED CHECK 4/CASH RECEIVED 3Y I DATE .RECEIVED <br />