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S <br />I <br />T <br />E <br />i <br />A <br />P <br />P <br />L <br />I <br />C <br />A <br />N <br />T <br />A <br />C <br />T <br />I <br />V <br />E <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />C <br />L <br />0 <br />S <br />U <br />R <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTALTH DIVISION <br />Uâ–ºMOUND STORAGE TANK PROGRAM- FEE YORKSHEETM <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />at SITE <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />CITY <br />STATE <br />ZIP CODE <br />ETYPEof APPLICATION <br />ure, Installation, etc.) <br />TOTAL <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minim <br />1986 1987 <br />1988 <br />1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />L <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br />_ $624.00 minim <br />$ <br />XXXX XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXXXXXXX <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXXXXXXX <br />TANK FEE = S50.00/TANK <br />(Prior to January 1,1991) <br />$170/TANK (After <br />January 1, 1991) <br />S <br /># Tanks = <br />1986 <br />1987 <br />1988 1989 <br />1990 1991 1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />(multiply # by fee for <br />each year applicable) <br />XXXX <br />XXXX <br />XXXX XXXX <br />XXXX <br />R <br />$ <br />TANK PENALTY FEES ASSESSED <br />XXXX XXXX XXXX XXXX <br />XXXX <br />5 <br />N <br />TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />$ <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) <br />See California H & S Code, <br />Section 25287 <br />I <br /># Tanks x $56.00 <br />1988 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />C <br />CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE <br />= $78.00/hr <br />$ <br />TOTAL DUE <br />$ <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X <br />$234.00 = <br />$ <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minim <br />$ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br />_ $624.00 minim <br />$ <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />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 />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />= $234.00 minim <br />5 <br />R <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum <br />5 <br />N <br />TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />$ <br />I <br />S <br />C <br />CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE <br />= $78.00/hr <br />$ <br />TOTAL DUE <br />$ <br />FOR OFFICE USE ONLY <br />E <br />