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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�I <br />CONTACT NAME n_ <br />/l'i <br />TS <br />RG <br />(l( <br />1987 <br />1988 <br />'E <br />FACILITY ADDRESS SITE PHONE # with AREA CODE <br />3490 6. 2-d 0 wo S a_& l (a <br />& <br /># TANK(s) X $234.00 = S <br />P <br />CITY RTATE1 ZIP CODE r # of TANKS �1 <br />1 cA 95;1js_D1Q3 at SITE (O\)TW <br />V <br />TEMPORARY <br />CLOSURE <br />(Plan Review & Inspections) <br />P <br />A��CANT/BILLING NAME ` <br />APPLI NT CONTAfJ NAME <br />= S234.00 minimum S <br />D <br />r <br />APPLICANT <br />XXXX <br />XXXX <br />XXXX <br />C <br />N <br />MAILING ADDRESS <br />-14 <br />F. <br />PHONE # WITH AREA CODE <br />�R � � -(O� lile7-7(y(T7� <br />T <br />C[SYI �I /L T, ! <br />CJ'.IFOe � 1\{-,h.)•ILr1'(l1 <br />TATE <br />ZCZ `E TYPE of APPLICATION <br />(Closure, InstaLlacion, eteJ �%SL(i2.Q,, <br />TOTAL <br />C <br />PERMANENT <br />CLOSURE <br />(Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) /✓° S 30/ TA 63,?oz- <br />, <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = S <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />U <br />TEMPORARY <br />CLOSURE <br />(Plan Review & Inspections) <br />I TANK I.D. #(s <br />1 <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum S <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />S XXXXXXXX <br />A <br />E <br />TEMPORARY <br />CLOSURE <br />FEE = S78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />I XXXX <br />XXXX <br />XXXX <br />XXXX <br />S XXXXXXXX <br />I <br />V <br />TANK FEE = 550.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK <br />(After <br />January 1, <br />1991) <br />E <br /># Tanks = <br />1988 <br />1989 1990 11991 <br />11992 <br />1993 <br />1 1994 <br />1995 <br />1996 <br />1997 <br />1998 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />X%XXXXXX <br />I XXXX %XXX <br />XXXX <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX XXXX xxxx <br />XXXX <br />S <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=S18.50 <br />S <br />T <br />Y <br /># Tanks x $8.00 <br />1988 through 1993 <br />(S56) <br />1993 <br />through <br />1997 <br />($56) <br />1998 <br />SURCHARGE FOR 1998 <br />XXXXXXXXXXXXxxxxxxXXXXXXXXX <br />XXXXXXXXXXXXXxxxxxxxXXX <br />S <br />C <br />PERMANENT <br />CLOSURE <br />(Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) /✓° S 30/ TA 63,?oz- <br />, <br />l <br />0 <br />CLOSURE FEE = 878.00/hour (3 hours minimum/TANK) <br /># TANK(s) C X S234-00 = 5 Up <br />S <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum 5 <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = S <br />U <br />TEMPORARY <br />CLOSURE <br />(Plan Review & Inspections) <br />I TANK I.D. #(s <br />1 <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum S <br />R <br />R <br />I <br />E <br />TEMPORARY <br />CLOSURE <br />FEE = S78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />TANK LD. #(s) <br />AMOUNT RECEIVED <br />L <br />A <br />N <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum 5 <br />R <br />REPAIR FEE (Workp(an Review & Construction Inspections) I <br />TANK LD. #(s) <br />AMOUNT RECEIVED <br />_._........ _ <br />I CHECK #/CASH I .RECEIVED BY I DATE RECEIVED - <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = S <br />_.........—.— <br />_ <br />A <br />1 <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= S234.00 minimum S <br />41 TRANSFER FEE = S20.00 <br />11 <br />CONSULTATION FEE = S78.00/hr <br />FM OFFICE USE ONLY <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />i S <br />I SS <br />TOTAL DUE S <br />-� <br />SWEEPS # <br />I COMPUTER # <br />LOC CODE I DIST CODE <br />AMOUNT RECEIVED <br />_._........ _ <br />I CHECK #/CASH I .RECEIVED BY I DATE RECEIVED - <br />simam <br />_.........—.— <br />EH 23 032 (REVISED 1-12-98) t <br />