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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />T <br />S <br />U <br />TEMPORARY CLOSURE <br />TOTAL <br />TANK I.D. #(s) <br />R <br />E <br />'E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />1986 <br />1487 <br />11988 <br />3 <br />1990 <br />INSTALLATION PLAN <br />CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />PLAN CHECK FEE = <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />XXXX <br />at SITE <br />I XXXX <br />XXXX <br />XXXX <br />S XXXXXXXX <br />A <br />P <br />P <br />APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br />L <br />I <br />C <br />KATLTAG—ADDRE5S APPLI NT—PHONE--"TH AREA—CODE <br />A <br />W! <br />T <br />CITY <br />STATE <br />ZIP CODE TYPE of APPLICATION <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />(Closure, Installation, etc.) <br />C <br />PERMANENT CLOSURE <br />(Removal or Authorized Closure -in -Place) <br />I TANK I.O. #(s) <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />I 9 TANK(s) X 5234.00 = S <br />S <br />U <br />TEMPORARY CLOSURE <br />TOTAL <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE <br />FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum S <br />1986 <br />1487 <br />11988 <br />� 1989 <br />1990 <br />INSTALLATION PLAN <br />CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />PLAN CHECK FEE = <br />S78.00/hour (8 hours minimum/FACILITY) <br />= $624.00 minimum <br />S <br />S <br />XXXX <br />XXXX <br />I XXXX <br />XXXX <br />XXXX <br />S XXXXXXXX <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />XXXX <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 1, 1991) <br />E <br /># Tanks = <br />1988 <br />1989 <br />1990 <br />1991 <br />+ 1992 <br />1993 1994 <br />1995 <br />11996 <br />1997 <br />1998 <br />F <br />(multiply # by fee for <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />I <br />I <br />S <br />A <br />each year applicable) XXXX <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX <br />XXXX <br />XXXX <br />I XXXX <br />XXXX I <br />I <br />I <br />I <br />S <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br />S <br />T <br />Y <br /># Tanks x 38.00 <br />1988 through 1993 <br />(S56) <br />1993 through <br />1997 <br />(S56) <br />1998 <br />SURCHARGE FOR 1998 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />C <br />PERMANENT CLOSURE <br />(Removal or Authorized Closure -in -Place) <br />I TANK I.O. #(s) <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />I 9 TANK(s) X 5234.00 = S <br />S <br />U <br />TEMPORARY CLOSURE <br />(Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE <br />FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum S <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />P <br />INSTALLATION PLAN <br />CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = <br />S78.00/hour (8 hours minimum/FACILITY) <br />= $624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />S <br />MTRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I i S <br />I <br />S I <br />C1 CONSULTATION FEE = S78.00/hr 1 SAMPLING INSPECTION FEE = 578.00/hr S <br />TOTAL DUE I S <br />FOR OFFICE USE ONLY <br />PW 21 nA2 (RFVISFD 1-12-98) <br />