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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S FACILITY SITE NAME <br />FACILITY qONTACT NAME <br />TANK I.D. #(s) <br />L <br />0 <br />T <br />E FACILITY DORESS <br />SITE PHONE # with AREA CO <br />Let) <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />CITY -- <br />STATE <br />ZIP CODE <br /># of TANKS <br />A ���x��,�� —� <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />1986 <br />at SITE <br />P <br />P APPLICANT/BILLI NAA E <br />APPLIC T CONTACT NA / <br />1990 <br />C MAILING AD ESS <br />PLICANT PHONE # WITH AREA COD <br />a0 1- f J,F <br />A �� �Zy <br />N , <br />TI CITY <br />ST TE <br />IIP CODE <br />TYPE of APPLICATION <br />Installation, etc.) <br />(Closure, <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) J <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br />` # TANK(s) X 5234.00 = $ <br />S <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />_ $234.00 minimum S <br />TOTAL <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.O. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />1986 <br />1487 <br />1 1988 11989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />XXXX <br />xxxx-1--mq <br />XXXX <br />I XXXX <br />S xXXXXXXX <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />xxxX <br />XXXX <br />XXXX I <br />XXXX <br />XXXX <br />S XXXXXXXX <br />I <br />V <br />TANK FEE = S50.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK <br />(After <br />January <br />1, 1991) <br />E <br /># Tanks = <br />1988 <br />1989 <br />1990 <br />1991 <br />11992 <br />1993 1994 <br />1995 <br />11996 ( <br />1997 <br />1998 <br />F(multiply <br /># by fee for <br />A <br />each year applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />S <br />C <br />TANK PENALTY FEES ASSESSED <br />I XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />'I <br />$ <br />L <br />I <br />STATE SURCHARGE.FOR NEW FACILITIES ONLY=518.50 <br />$ <br />T <br />Y <br /># Tanks x 38.00 <br />1988 through 1993 <br />($Sb) <br />1993 through <br />1997 ($56) <br />1998 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />= <br />S <br />SURCHARGE FOR 1998 <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) J <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br />` # TANK(s) X 5234.00 = $ <br />S <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />_ $234.00 minimum S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.O. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum S <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum <br />S <br />M TRANSFER FEE = S20.00 <br />I — <br />S <br />C CONSULTATION FEE = $78.00/hr <br />FOR OFFICE USE ONLY <br />T:ssasa:aa:a:a BMs::=zaaaaa:a:s:a <br />SWEEPS # COMPUTER # LOC CODE <br />cu P1 nip fRFVTSFD 1-12-981 <br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />SAMPLING INSPECTION FEE = $78.00/hr <br />DIST CODE�AMOUNT RECEIVED i CHECK #/CASH <br />I S <br />1 <br />i <br />TOTAL DUE S <br />RECEIVED BY ( DATE RECEIVED <br />REPAIR FEE (Workplan Review & Construction Inspections) I <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 5234.00 = S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />_ $234.00 minimum S <br />R <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) <br />_ $234.00 minimum S <br />M TRANSFER FEE = S20.00 <br />I — <br />S <br />C CONSULTATION FEE = $78.00/hr <br />FOR OFFICE USE ONLY <br />T:ssasa:aa:a:a BMs::=zaaaaa:a:s:a <br />SWEEPS # COMPUTER # LOC CODE <br />cu P1 nip fRFVTSFD 1-12-981 <br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />SAMPLING INSPECTION FEE = $78.00/hr <br />DIST CODE�AMOUNT RECEIVED i CHECK #/CASH <br />I S <br />1 <br />i <br />TOTAL DUE S <br />RECEIVED BY ( DATE RECEIVED <br />