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' SAN JOAOUIN COUNTY OIC HEALTH SERVICES - ENVIRONMENTAL HEALTH D;.YSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />Z <br />T <br />'E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />TQTAL <br />`? % ' D RL <br />S <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />11989 <br />1990 <br />at SITE <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />XXXX <br />XXXX <br />XXXX <br />I <br />C <br />MAILING ADDRESS <br />PPLICANT PHONE # WITH AREA CODE <br />11 <br />T <br />CITY <br />STATE <br />ZIP CODE <br />T E APPLICATION <br />C <br />T <br />(Closure, Installation, etc.) <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) <br />TANK I.D. #(s) <br />E <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />I # TANK(s) X S234.00 = S <br />TQTAL <br />S <br />A <br />1986 <br />1987 <br />� 1988 <br />11989 <br />1990 <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />5234.00 minimum <br />S <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />xxxx <br />S XXXXXXXX <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />I XXXX <br />I XXXX <br />XXXX <br />S xxxxxxxX <br />I <br />V <br />TANK FEE = S50.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK <br />(After <br />January 1, 1991) <br />E <br />9 Tanks = <br />1988 <br />1989 <br />1990 <br />1 1991 <br />1 1992 <br />1993 <br />1994 <br />1 1995 <br />( 1996 <br />1997 <br />1998 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />I <br />I <br />I <br />I <br />S <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=S18.50 <br />S <br />T <br />Y <br /># Tanks x $8.00 <br />1988 through 1993 <br />(S56) <br />1993 through <br />1997 <br />(S56) <br />1998 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXxxxxxxxxxxxxxXxxxX <br />S <br />SURCHARGE FOR 1998 <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) <br />TANK I.D. #(s) <br />E <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />I # TANK(s) X S234.00 = S <br />f <br />S <br />A <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />S <br />R <br />El <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = <br />f <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum <br />S 3 W <br />M TRANSFER FEE = $20.00 <br />I <br />S <br />C. CONSULTATION FEE = S78.00/hr <br />FM nFFTCF t1SF nYLY <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = $78.00/hr <br />S <br />S <br />TOTAL DUE 1 S % -:l Q W <br />cm ;01 n17 (RFVTSFD 1-12-98) <br />