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C <br />EA IVSION <br />SAN JOAOUIN COUBLIC HEALTH SERVICES - ENVIRONMENTAL HEA* <br />TANK I.D. #(s) <br />L <br />O <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s)4— X $234.00 = $ p® <br />UNDER OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />,ILITY SITE NAME <br />CEN <br />$ <br />FACILITY CONTACT NAME <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />FACILITY P"', <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br />SITE PHONE # with AREA CODE <br />ap22RESS <br />I DJ <br />p, <br />8 <br />CITY <br />ZIP CODE <br /># of TANKS <br />/nSTATE <br />at SITE <br />A <br />ryt.R_ <br />/J�.33 <br />P <br />P <br />APPLICA T/ ILLI G N E <br />APPLICANT NTA T NA E� <br />L <br />t <br />C <br />MAILING ADDRESS <br />I APPLICANT PHONE # WITH REA <br />CODE <br />N <br />T <br />CITY <br />STATE <br />CODE <br />TYPE of APPLICATION <br />QZIP <br />(Clow , installation, etc.) <br />TOTAL <br />1986 11987 11988 11989 <br />11990 <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) _ $100.00 <br />XXXX I XXXX XXXX XXXX <br />XXXX <br />$ XXXXXXXX <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX XXXX XXXX i XXXX <br />XXXX <br />$ XXXXXXXX <br />I <br />V <br />TANK FEE _ $50.00/TANK <br />(Prior to January 1,1991) <br />$170/TANK <br />(After January 1, <br />1991) <br />E <br /># Tanks = <br />1988 1989 1990 1991 1992 1993 <br />1994 1995 1996 11997 <br />1998 <br />F <br />(multiply # by fee for <br />$ <br />A <br />each year applicable) <br />XXXX ( XXXX XXXX XXXX XXXX <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX XXXX <br />I �Xxxx��$ <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 <br />$ <br />T <br />Y <br /># Tanks x $8.00 <br />1988 through 1993 ($56) <br />1993 through 1997 ($56) <br />1998 <br />XXXXXXXXXXXXXXXXXXXXXXX N <br />$ <br />SURCHARGE FOR 1998 I XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace) I <br />TANK I.D. #(s) <br />L <br />O <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s)4— X $234.00 = $ p® <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />$ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />I TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />$ <br />R <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />$ <br />M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />I <br />S <br />C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br />FOR OFFICE USE ONLY <br />.......................................... <br />...........:s::::; s:s::s::s::tt:s:::s:;:;::: tas.................._ [-:::::::::::: <br />SWEEPS # I COMPUTER # I LOC CODE DIST CODE ( AMOUNT RECEIVED I CHECK #/CASH <br />$ <br />(REVISED 1-12-98) <br />