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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRM04ENTAL HEALTH DIVSION <br /> WMRGRa= STORAGE TANK PROGRAM - FEE WORKSHEUM <br /> S FACILITY SITE NAME FACILITY CO ACT NAME <br /> I71 <br /> T v <br /> E FACILITY ADDRESS a SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> 1 <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 � 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX XXXX XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks = 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 <br /> F (multiply # b fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX I I S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX I $ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 $ <br /> T <br /> Y # Tanks-4 x $8.00 1988 through 1990 ($56) 1991 through 1996 ($56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minim/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 = 578.00/hour (3 hours minim/FACILITY) 5234.00 minim $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> PP! <br /> L <br /> A <br /> N ALAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 minim S <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 minim/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = S234.00 minim $ <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minim/FACILITY) = S234.00 minim S <br /> N TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE S c <br /> FOR OFFICE USE ONLY <br /> M::.........._..._............._.........................__...._..... .. �_........._._... __._.. _.—._ ...__ ._ <br /> ,:tea•:=�::�:.:�:::=::s:::-�:_�:._-:::a:a::t:stsss:::-.•:: -.-e--=.�= ..,a :�•::::.:.•—�-�:�.—�:�:-..::-.�:_��_._........._._..�..._......-y........_.._.......__..._.__._.. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH —RECEIVED BY I DATE RECEIVED <br /> Li <br /> -.............................................-..............-- ----_—••••-•_.........::�:._......-..-..._.. :-................ .�-:r:: ::— ._ _._..:.._ _ :.: �—:__:-.._— _.........___...........................................__..._._ <br /> EH 23 032 (REVISED 5-27-97) G <br />