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SAN JOAQUIN C 'TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL P TH DIVISION <br /> UNC -JND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> :ACILITY SITE NA E FACILITY C NTACT NAME <br /> E FACILITY ADDRESS SITE PHONE I with AREA CODE <br /> o dI <br /> CITY STATE ZIP CODE ;* of TANKS <br /> A CA- at SITE scocr\ <br /> P <br /> P APPLICAN /BILLING NAME APPLICANT CONTAC NAME <br /> L rue( c6rna u1\ <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE 4 WITH AREA CODE <br /> N <br /> I <br /> T CITY STATE ZIP C00 TYPE of APPLICATION Il <br /> �fn S"M (Closure, Installation, etc.) �1S�QlIQ�� <br /> TOTAL <br /> 1986 1987 1988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A I XXXX XXXX i XXXX XXXX XXXX $ XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX 1 XXXX XXXX I XXXX 5 XXXXXXXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 4 Tanks = 1986 1987 11988 11989 1990 1991 11992 1993 1994 11995 1996 IFl 3a 00 6 <br /> F (multiply by fee for <br /> AI each year applicable) XXXX XXXX XXXX XXXX XXXX I $3 O <br /> II TANK PENALTY FEES ASSESSED XXXX I XXXX XXXX I XXXX XXXX I S <br /> L <br /> 11 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T 0300 <br /> Yanks_�x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) u 3A ODS <br /> TS <br /> I $112,6o <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. 4(s) <br /> L <br /> �-- <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimun/TANK) # TANK(s) X $234.00 = S <br /> S <br /> UI TEMPORARY CLOSURE (P(an Review & Inspections) TANK I.D. 4(s) <br /> R <br /> El TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum $ <br /> PI INSTALLATION PLAN CHECK (Plan Review I Construction Inspections) TANK I.D. 4(s) <br /> L, <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum 5 o 1 ,6o <br /> i <br /> R) REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E, <br /> P TANK LINING REPAIR FEE = 378.00/hour (3 hours minimum/TANK) TANK(s) X $234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = 378.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum S <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr 5 <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S <br /> TOTAL DUE Slb O <br /> FOR OFFICE USE ONLY <br /> ... -.::__::::_�. .:::� .. <br /> SWEEPS COMPUTER 9 I LOC CODE I DIST CODE AMOUNT RECEIVED I CHECK */CASH RECEIVED BY DATE RECEIVED _ <br /> ......................................................................::::..::•...........:-:--:::-::::::::................. -::::_.:$--::_:._:. . .--_....:-:—,.—.::::: -:-::-:�1 :: _.—:_—=:-:. _. —:.—:-:-_::::::-.--:_=_._—:::_-::.---::•s <br /> 9 <br />