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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - EgVIRONMEMTAL HEALTH OIVSI011 <br /> UNDF -AIM STORAGE TANK PROGRAM - FEE WORKSHEET <br /> v � <br /> SI FAC:LiTY SITE NAME I FACILITY CC14TACT NAME <br /> t U yn <br /> I� <br /> u <br /> El FACILITY AOORESS SITE PHONE $ with AREA CODE <br /> CII ` I TA EI ZIP CCnEI a of TANKS <br /> A S'all ac SITE <br /> J P <br /> P APP'-(CANT/BILLING NAME APPLICANT CONTACT NAME <br /> -+ Cl .`1AIL!.yG A00RESS I 71CANT ?HONE .,' WITH AREA CSE <br /> N <br /> T C!i'' STATE ZIP CCOE I TY E or APPLICATION � <br /> (Closure, Installation, etc.) I <br /> TOTAL <br /> 1986 11987 11988 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A I XXXX XXXX I XXXX XXXX I XXXX 5 XXXXXXXX <br /> C' <br /> TI FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX I xXXX i XXXX I xxXX i XXXX 5 xXXXXXXX <br /> u l <br /> V� TANK = 550.00/TANK (Prior co January 1,1991) i 5170/TANK (After January 1, 1991) <br /> E' II I I I I I i I I i <br /> Tanks = 1988 1989 1990 1991 1992 1993 i99� 1995 1996 1997 1998 <br /> F (multiply J by fee for <br /> u A each year applicab(e) XXXX XXXX I XXXX i XXXX IXXXX I ( I i I I S <br /> (I TANK ?E'IALTY FEES ASSESSED i XXXX I XXXX I XXXX I xXXX IXXXX I I I I I I 15 <br /> L, <br /> (I STATE SURCHARGE FOR VEST FACILITIES ONLY=518.50 5 <br /> Y� 1 Tanxs x 58.00 1988 through 1993 (556) I 1993 through 1997 (556) 1998 I <br /> SURCHARGE FOR 1998 i xXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX i 15 <br /> Ci ?ERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.J. �'(s) ! <br /> L' III <br /> `—' 01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) i TANK(s) X 5234,00 = 15 a3 6D <br /> S, <br /> UI TEMPORARY CLOSURE (Plan Review b Inspections) I TANK I.D. ;*(s) <br /> .R <br /> EI TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P! !NSTALI-ATION ?'--AN CHECK (Plan Review b Construction Inspections)I TANK I.D. 4(s) <br /> L� <br /> Al <br /> N ?LAN CHECK FEE = 578.00/hour (8 hours minimi/FACILITY) 5624.00 minimum S <br /> �+ Rl .RE?AIR :EE (Workplan Review 3 Construction Inspections) I TANK I.O. ;$(s) <br /> PI TANK -(MING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I TANK(s) X 5134-00 = S <br /> A <br /> u Il TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) 5234,00 minimum I S <br /> R <br /> ?IP!NG RE?AIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimrn S <br /> Al TRANSFER FEE = 520.00 I ( UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I S <br /> S', <br /> II I I I I <br /> Cl CCNSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> `J TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> u 54EE?S I COMPUTER x I LOC CODE I OIST CODE I AMOUNT RECEIVED I CHECK -/CASH I RECEIVED 3Y I DATE RECEIVED <br /> u <br /> :� 23 032 (REVISED 1-12-98) <br />