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Ci PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK T.D. #(s) <br />L. <br />01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) i TANKS) <br />S X 5234.00 = S <br />UI TEMPORARY CLOSURE (Plan Review & Inspections) 1 TANK I.D. #(5) <br />R' <br />El TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br />P; INSTALLATION PLAN CHECK (PLan Review & Construction Inspections)I TANK I.D. #(s) <br />L' <br />Al <br />NI PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) - 5624.00 minimum S <br />RREPAIR FEE (Workplan Review & Construction Inspections) i <br />TANK I.D. #(s) <br />a ' <br />A <br />P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I <br /># TANK(s) X S234.00 = <br />S <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />= $234.00 minimum <br />1 <br />S <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />1 SI <br />FACILI 4 "ITE NAM( <br />1988 <br />FACILITY C TACT NAME <br />1990 <br />T <br />! <br />ANNUAL FACILITY FEE (Prior <br />to January1986 <br />i, 1491, = <br />5100.00 <br />EI <br />FACILITY ADDRESSSItE <br />S4 I <br />PHONE with AREA CODE <br />Ci CONSULTATION FEE = S78.00/hr ' 1 SAMPLING INSPECTION FEE <br />Al <br />S <br />535-- — <br />AI <br />CITY <br />XXXX 1 <br />STATEI <br />ZIP CODE i of TANKS <br />�� at SITE <br />5 XXXXXXXX <br />P; <br />P! <br />APPLICANT/BILLI <br />�71� <br />E <br />{ APPLI N CONTACT NAME <br />T'. <br />I 1 <br />XXXX <br />XXXX i <br />, <br />C <br />MAILING ADDRESS <br />S XXXXXXXX <br />APPLICANT PHONE A WITH AREA CODE <br />Al, <br />N' <br />2115-- <br />h <br />Ci �. <br />I <br />� <br />315 .7 <br />T' <br />CIT"/TE. <br />9 <br />ZIP CODE TYPE o1 APPLICATION <br />(Ly (Closure, Installation, etc.) <br />Ci PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK T.D. #(s) <br />L. <br />01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) i TANKS) <br />S X 5234.00 = S <br />UI TEMPORARY CLOSURE (Plan Review & Inspections) 1 TANK I.D. #(5) <br />R' <br />El TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br />P; INSTALLATION PLAN CHECK (PLan Review & Construction Inspections)I TANK I.D. #(s) <br />L' <br />Al <br />NI PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) - 5624.00 minimum S <br />RREPAIR FEE (Workplan Review & Construction Inspections) i <br />TANK I.D. #(s) <br />P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I <br /># TANK(s) X S234.00 = <br />S <br />TOTAL <br />= $234.00 minimum <br />1 <br />S <br />Ri <br />1987 <br />1988 <br />1489 <br />1990 <br />! <br />ANNUAL FACILITY FEE (Prior <br />to January1986 <br />i, 1491, = <br />5100.00 <br />S4 I <br />Ci CONSULTATION FEE = S78.00/hr ' 1 SAMPLING INSPECTION FEE <br />Al <br />S <br />j XXXX <br />XXXX <br />XXXX 1 <br />XXXX <br />I XXXX <br />5 XXXXXXXX <br />C' <br />T'. <br />FACILITY PENALTY FEES ASSESSED (If ADplicable) <br />XXXX <br />; XXXX <br />XXXX i <br />XXXX <br />XXXX <br />S XXXXXXXX <br />I <br />9 <br />V; <br />TANK FEE = S50.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK <br />(After <br />January <br />1, 1991) <br />E' <br />Tanks = <br />1487 1988 1989 <br />1490 , 1491 <br />1992 1993 <br />11994 <br />1995 i <br />1996 <br />1997 <br />Fi <br />s <br />(multioty R by fee or <br />Ai <br />each year a=Licabte) <br />XXXX XXXX f XXXX <br />XXXX 1XXXX <br />j <br />j <br />I S <br />C: <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX XXXX XXXX <br />I XXXX iXXXX <br />; <br />I <br />! <br />j <br />S <br />L <br />II <br />STATE SURCHARGE FOR NEN FFACILITIES <br />ONLY = $18.50 <br />QS <br />T' <br />i <br />Y; <br />W Tanks x S8.001988 <br />through <br />1990 (356) <br />1991 through 1996 (S56) <br />1997 <br />1 <br />SURCHARGE FOR 1997 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />s <br />Ci PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK T.D. #(s) <br />L. <br />01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) i TANKS) <br />S X 5234.00 = S <br />UI TEMPORARY CLOSURE (Plan Review & Inspections) 1 TANK I.D. #(5) <br />R' <br />El TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br />P; INSTALLATION PLAN CHECK (PLan Review & Construction Inspections)I TANK I.D. #(s) <br />L' <br />Al <br />NI PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) - 5624.00 minimum S <br />RREPAIR FEE (Workplan Review & Construction Inspections) i <br />TANK I.D. #(s) <br />P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I <br /># TANK(s) X S234.00 = <br />S <br />A <br />II TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum <br />1 <br />S <br />Ri <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum <br />S <br />M+ TRANSFER FEE = S20.00 + UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />I, <br />S4 I <br />Ci CONSULTATION FEE = S78.00/hr ' 1 SAMPLING INSPECTION FEE <br />= S78.00/hr 1 <br />S <br />TOTAL DUE I S <br />FOR OFFICE USE ONLY <br />SWEEPS # I COMPUTER # ( LOC CODE DIST CODE I AMOUNT RECEIVED ( CHECK #/CASH RECEIVED 3Y ~I- -DATE-RECEIVED <br />EH 23 032 (RFVt9Fn S -77-07N <br />