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. 0 0 <br />I , . 4 1 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSICIN <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />Si <br />FACILITY SITE NAME <br />Is) <br />FACILITY CONTACT NAME <br />T <br />PERMANENT CLOSURE (Removal or Authorized CLosure-in-Ptace) I <br />TANK I.D. #(S) <br />e EI <br />FACILITY ADDRESS_ <br />1 t7 <br />I SITE PHONE # with AREA CODE <br />UI <br />R' <br />76 <br />TANK I.D_ #(s) <br />j <br />AI <br />CITY <br />t �( ���- <br />I <br />,ATEI ZIP CODE i of TANKS E <br />at SITE <br />, <br />INSTALLATION PLAN CHECK (Plan Review & Construction Insoections)I <br />TANK 1.D. :(S) <br />q <br />i <br />Al <br />N1 PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br />P! <br />APPLICANT/BILLING NAME <br />/ <br />APPLI- NT dCMTACT NAKED ; <br />I <br />E` <br />REPAIR FEE (Workplan Review & Construction Inspections) i <br />C! <br />A <br />MAILING ADDRESSAPPLICANT <br />2o <br />PHO = -WITH AR -A gQPE <br /># TANK(s) X S234.00 = <br />i S <br />t�y <br />(� <br />!/ <br />N' <br />1 S 6 <br />1.411. 4tc <br />S <br />T� <br />CITY <br />II <br />STATE•i ZIP CODE TYPE of APPLICATION i <br />I Installation, <br />4 <br />Ir A172J <br />I <br />ii (Closure, etc.) <br />ANNUAL FACILITY FEE (Prior to January i, 1991) = S100-00 <br />Al <br />TOTAL <br />1986 1987 1988 1 1989 11990 <br />I XXXX XXXX i XXXX i XXXX I XXXX S XXXXXXXX <br />XXXX XXXX XXXX j XXXX XXXX i S XXXXXXXX <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) i 5170/TANK (After January 1, 1991) <br />Tanks = 1987 1988 1989 j 1990 1991 1992 1993 11994 1995 1996 j 1997 <br />(multioly # by fee for <br />each year aopiicable) XXXX XXXX XXXX I XXXX iXXXX j i I S <br />� i C <br />i <br />TANK PENALTY FEES ASSESSED XXXX XXXX XXXX I XXXX iXXXX S <br />j STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 is <br />W Tanks x S8.00 1988 through 1990 (556) 1991 through 1996 (S56) 1997 <br />SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br />EN 23 032 (RFvrSpn S- »-ori <br />Ci <br />l; <br />PERMANENT CLOSURE (Removal or Authorized CLosure-in-Ptace) I <br />TANK I.D. #(S) <br />01 <br />S' <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) i <br />y TANK(s) X 5234.00 = <br />S <br />UI <br />R' <br />TEMPORARY CLOSURE (Plan Review & Inspections)) j <br />TANK I.D_ #(s) <br />Ej TEMPORARY CLCSURE FEE = $78.00/hour (3 hours minimum/FACILITY) ' <br />S234.00 minimum <br />S <br />P! <br />L' <br />INSTALLATION PLAN CHECK (Plan Review & Construction Insoections)I <br />TANK 1.D. :(S) <br />q <br />i <br />Al <br />N1 PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br />= $624.00 minimum <br />1 <br />S <br />E` <br />REPAIR FEE (Workplan Review & Construction Inspections) i <br />TANK I.D. :(s) <br />Pi <br />AL <br />TANK LINING REPAIR FEE = S78-00/hour (3 hours minimum/TANK)I <br /># TANK(s) X S234.00 = <br />i S <br />t�y <br />II <br />R <br />TANK RETROFIT REPAIR PEE = S78.00/hour (3 hours min./FACILITY) <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= 5234.00 minimus <br />= S234.00 minimum <br />1 S 6 <br />1.411. 4tc <br />S <br />II <br />TRANSFER FEE = S20.00 ( I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I i <br />S <br />St <br />I <br />I <br />1 <br />C. <br />CONSULTATION FEE _ $78.00/hr ! I SAMPLING INSPECTION FEE <br />= S78.00/hr , <br />S <br />FOR OFFICE USE ONLY <br />TOTAL DUE <br />S ? <br />, <br />t <br />SWEEPS I COMPUTER ( LOC CODE DIST CODE I AMOUNT RECEIVED ( <br />CHECK R/CASH RECEIVED BY <br />DATE RECEIVED <br />I <br />EN 23 032 (RFvrSpn S- »-ori <br />