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A <br />F <br />F <br />L <br />I <br />C <br />A <br />N <br />1 <br />SAN JOAOUIN CIPTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION <br />UNDERGROUND STORAGE TANK PR - FEE WORKSHEET <br />a....... �.4c •uut FACILITY CONTACT NAME <br />C <br />L <br />0 <br />S <br />U <br />R <br />E <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />I TANK I.D. #(s) <br />FACILITY ADDRESS <br />SITE PHONE # with A EA CODE <br />TEMPORARY CLOSURE (Plan Review 8 Inspections) <br />TANK I.D. #(s) <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />f <br />N <br />PLAN CHECK FEE = 578.00/hoar (8 hairs minimum/FACILITY) <br />at SITE <br />APPLICAN /BILLING NAME <br />APPLICANT CONTACT NAME <br />1988 <br />ILING AFgESS _ <br />6e --)Tc �5 <br />APPLICANT PHONE <br />/ # WITH AREA CODE <br />f ' 41 LM <br />CITY � <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />C <br />L <br />0 <br />S <br />U <br />R <br />E <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />I TANK I.D. #(s) <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = S <br />TEMPORARY CLOSURE (Plan Review 8 Inspections) <br />TANK I.D. #(s) <br />=ORARYCLOSURE FEE = 578.00/hair (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />TOTAL <br />N <br />PLAN CHECK FEE = 578.00/hoar (8 hairs minimum/FACILITY) <br />= S624.00 minimum <br />S <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />E <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />P <br />TANK LINING REPAIR FEE - S78.00/hoar (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />S <br />A <br />A <br />t <br />TANK RETROFIT REPAIR FEE to 578.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum <br />S <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />S XXXXXXXX <br />C <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= S234.00 minimum <br />S <br />N <br />TRANSFER FEE _ $20.00' UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />S <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />.S <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />S XXXXXXXX <br />I <br />C <br />CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE <br />= S78.00/hr <br />S <br />V <br />TANK FEE = 550.00/TANK <br />(Prior to January 1,1991) <br />FOR OFFICE USE ONLY <br />5170/YANK <br />(After <br />January <br />1, 1991) <br />E <br />IH COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVE <br />I I <br />CHECK WASH I RECEIVED BY <br />DATE RECEIVED <br />—p <br />5 <br />I <br />_ <br /># tanks = <br />1988 1989 <br />1990 1991 <br />11992 <br />1993 1994 <br />11995 <br />1996 <br />1997 <br />1998 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />XXXX xXXX <br />XXXX xxxx <br />XXXX <br />I <br />( <br />5 <br />G <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX XXXX <br />XXXX ' XXXX <br />rXxxX <br />S <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br />S <br />T <br />Y <br /># Tanks x $8.00 <br />1988 through 1993 <br />(S56) <br />1993 through 1997 (S56) <br />1998 <br />XXxxxxxxxXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />SURCHARGE FOR 1998 <br />C <br />L <br />0 <br />S <br />U <br />R <br />E <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />I TANK I.D. #(s) <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = S <br />TEMPORARY CLOSURE (Plan Review 8 Inspections) <br />TANK I.D. #(s) <br />=ORARYCLOSURE FEE = 578.00/hair (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = 578.00/hoar (8 hairs minimum/FACILITY) <br />= S624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review 3 Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE - S78.00/hoar (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />S <br />A <br />t <br />TANK RETROFIT REPAIR FEE to 578.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= S234.00 minimum <br />S <br />N <br />TRANSFER FEE _ $20.00' UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />S <br />.S <br />C <br />CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE <br />= S78.00/hr <br />S <br />TOTAL DUE <br />5 ' <br />FOR OFFICE USE ONLY <br />mEREfEi44£E!4!A..iii?Ii9?S4:mv:!!:;sg!ppr!,r.R.!!.i.!.i.!.!. <br />!Fpd�414H i EE440 6m S !!i <br />BROWN� EiRR.lghi!iii??:F!!M::Mi!9�Rf4!R�DSWEPS <br />IH COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVE <br />I I <br />CHECK WASH I RECEIVED BY <br />DATE RECEIVED <br />—p <br />5 <br />I <br />_ <br />EN 23 032 (REVISED 1-12-98) <br />