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• SAN JOACUIN COLWY PUBLIC HEALTH SERVICES - ENVIRONMENTAL NEXILH DIVISION <br /> UNDqWND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHONE 9 with AREA CODE <br /> & <br /> CITY STATE ZIP CODE I # of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE 9 WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> CCiosure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) S170/TANK (Atter January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1489 1490 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX 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 # Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> $ a <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK E.D. #(s) <br /> L <br /> 0 CL051URE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = s <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) $04.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hags minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hoar (3 hairs minimum/TANK) # TANK(s) X 5234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimus S <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minim&m/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION a $78,00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION -FEE _ S78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> CEIVED'.;: <br /> SWEEPS # COMPUTER # LOr CODE DIST.CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY J i GATE RE <br /> a S t <br /> s <br />