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qq <br /> SAN JOAQUIN TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL OTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I f._ <br /> T <br /> E FACILITY ADDRESS SITE PHONE # Ath AREA CODE <br /> & <br /> CITY S ATE ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> 2�— <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADD S APPLICANT P ONE # WITH AREA CODE <br /> a/ - 7 <br /> N cY <br /> T CIT STATE ZIP CODE TYPE of APPLICAT IO v 3 p <br /> C (Closure, Installation, etc.) <br /> 1ILL c..;;LTOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX 5 XXXXXXXX <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1487 1488 1989 1990 1991 1492 1993 1994 1995 1996 1997 <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 $ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = 518.50 is <br /> T <br /> Y # Tanks x $8.00 1988 through 1990 ($56) 1991 through 1996 ($56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # 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) $234.00 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 hours minimum/FACILITY) = 5624.00 minimum $ <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 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimm/FACILITY) _ $234.00 minimum $ ®� <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> :::::::::•�:::::::::::::::::-::::::::::::::::::::::-::::::.:�:::::�::::::::_�::::�:::�::::::...._..._...._.._...__.__._.._.::�..�.�.:.=-Wim..--. :: ::::::�—: <-�.::::::::::::�:�y:.—•:.::�_..::.•�-.�-�_:..--.:.-w::�•m.•::::-:�:-...:.—..-::-•_.Y:::::::-.• <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> ..........:..:.:..._.....::::::::::::::::::::_::::::..................::::.................. w::::::::::: :W ..:.....__.:: .:: :W::_: ......�:.....=::M:::::::- �::............. <br /> EH 23 032 (REVISED 5-27-97) 0 <br />