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r <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL 11101 DIVISION <br /> UNDERGROUND STORAGE TANK PR - FEE UORKSHEET <br /> rE <br /> FACILITY SIT NAME FACILITY CONTACT NAME <br /> / SITE PHONE # with AREA CODE <br /> FACT TY ADDRESS STATE ZIP CODE # of TANKS <br /> CITY <br /> at SITE <br /> A <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N <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) = $100.00 XXXX XXXX XXXX XXXX XXXX 5 XXXXXXXXXXXXX <br /> A <br /> CXXXX XXXX XXXX XXXX XXXX 5 XXXXXXXXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> 1 •. <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks ,� 1486 1987 1988 1989 1990 1991 1992 1993 1494 1995 1 <br /> F (multiply 0 15y fee for 5 <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX70 <br /> C 5. <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX <br /> L <br /> i STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T1991 through 1997 <br /> Y # Tanks x $56.00 1988 through 1990 <br /> (Enter amount and year) S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L # TANK(s) X $234.00 = s <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> S <br /> U TEMPORARY CLOSURE (Plan Review $ Inspections) TANK I.D. #(s) <br /> RS <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. #(s) <br /> L <br /> A Js <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> ES <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 mini5 <br /> mum <br /> R S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br /> N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = S78.00/hr <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> a : n : 4F PiU?UUWWfilU441lilEtt!lEEIE!lUti!?W1WElE!UffifWWiUU!!6UEil!UIUtUUlSi!3SW4W!UEFlIaSFEUUiWUEWEWtm?i!tUUW!UtIiUW!£UItUUt!E!4WW?E!£UUtt!EtEtlWitlU!lWtmiUUU!i!U WEi?IWItiFUUEWWWa.E!9WUElU?mUU!EUEIU£FU?U£mUt!£USUtU <br /> mllmlWlidU?i?SFS?£!t!W!!d!tl.l£EIIitUU££!£if.t!U[W..lE4!EiWitt�!1WflEt£UEl4.11t.£W. <br /> {UUililEiial:LWSWIISIEilfi4iidm(F?4l3SEtl4?t3F4Fil?diiiili!![FlIW?FFi 3W!!!U!!iWlUiiUli{WlFSidFF i!UiIFFFdUUEUIIIilfIFUSUt{UIlFliiWli{iiliil!iiifdtUlUFiiUIUFmlUFiFiidlEU!!iWiiWiifilWllFiSFf!FidUSUlHiiiF4iiiUliS Wlii{IIWWl1{F31lii[iiiltliiliUWi?lilfliiii lUiUlFt!FW{i!1lWFigtttWWUiitliiftlU!liFiUF11UUilWtWiWUlUm <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> m <br /> 5 i <br /> ••a a r a a••a: r•a:r a an a!n•aIIII!?!!!ti?!!i!IE!!IS4SEt£EEIlW!!UUlEISIUESU!!UU!ltitU4t!!t!4.FUWlUUUIStdWUtfG E UI!?IUUWftm£41U!!!?ttl!i!atUi!!!W?AF?iWEltW!?!lttUttWi?lIWWflm?a!£t!!IWlitm WFlWI <br /> U!?i?ttt£i!!?F!ti?!f£l!i4?ilil?i4i?F??!?iEs?4FESF?ES!f?litiii??iiF?44Fia:4.11.!FE.alE4.l.4EaaF..EU;W44UF.aa..U. .i...tllEFWI.Fi 9..Ea 3. <br /> £IIFH!it£EI£Ui!{!UilttFEiilfSEililitUf}Uii£IIIFStiEEE?IIUE(!£FISF!}U4iFiiillEliFEFWiIUiWHUbli4imiUllWl IF3UFlUEFF4SIiiIISUiE{itUliiiiltilt(iiRfiiEiiimiUltititiliilU!INIIii1�U£FWFIW£WIUiilFillIIEWW£IUWUWid ilUEiiUWifUMUUU£WiittililllStilU£lifmk!imiii£tEU£ISliliiUEFkiW£IWiUii£IiN£WF IIIWIUWWii <br />