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SAN JOAQUIN COUN�,iPUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALW'DIVSION <br /> UNDERGROIAID STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T — Vim. Y SV =T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE � <br /> 6 C` g`' <br /> CITY <L STATE ZIP CODE # of TANKS <br /> at SITE <br /> P APPLICANT/BILLING NAME / APPLICANT CONTACT NAME <br /> C MAILING ADDRESS -,( APPLICANT PHONE 9 WITH AREA CODE <br /> A � :�: C' , �Itry-!( <br /> N <br /> T CITY STATE IP CODE TYp of APPLICATION <br /> (Mos nstal(ation, etc.) <br /> TOTAL <br /> 1986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A %X%x xxxx XXX% xxxx XX%X S %XXXX%%X <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx %XXX XXXX XXX% XXXX S %%XXX%%% <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> 41 Tanks = 1988 1989 1990 1 1991 11992 1993 1994 1995 1996 11997 1 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXX% %X%X xxxx XXX% I S <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX %XXX I XXXX XXXX I%XX% I I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 S <br /> T <br /> Y # Tanks x $8.00 1988 through 1993 (S56) 1993 through 1997 ($56) 1998 <br /> SURCHARGE FOR 1998 X%X%%X%%%xXx%X%XX%XX%X%%XXX XXXX%XXXxxxXxxxxxxxx%xX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimm/TANK) # TANK(s) '� _ X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 mini mm S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections)I TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimm S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E �Z <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minim /TANK) # TANK(s) X $234.00 IT: <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) _ $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = 5734.00 minimum S <br /> RTRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I S <br /> 1 <br /> S <br /> Ci CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE IT: $78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY ._ <br /> SWEEPS At COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK */CASH RECEIVED BY DATE RECEIVEDITT <br /> = - <br /> :: <br /> cw PS ni? CRFVISFO 1-12-98) <br />