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t r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> )ERGROUND STORAGE TANK PROGRAM - FEE WORKSH <br /> S FACIL^TY S�TE J�AME �Lvt �. J \ FACILITY CONTACT NAME p <br /> E FACIL T.Y ADDRESS �-�- r� SITE PHONE with AREA CODE _ <br /> CITY / STATE ZIP CODE #of TANKS <br /> A � �� ,� C ��lU at SITE v�� <br /> P � <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A XXXX XXXX XXXX )O= p s <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX =O, L bo S 100 <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1 _ 1986 1987 1988 1 1989 1990 1991 11992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX e 7 / ?v y% v % /o f`t 5?//m <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX I XXXX XXXX ��1 7�) I/ 7( i'710 ��l ' �� 5%,-)o <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> YI # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/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) = 5234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = S234.00 minimum 5 <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr ( 5 <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE 5 l <br /> FOR OFFICE USE ONLY _ ------- <br /> -SWEEPS # COMPUTER # LOC CODE DIST CODE —AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> = g <br /> EH 23 032 (REVISED 4-6-95) <br />