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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 FACILITY CONTACT NAME <br /> _ _ f <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 8 <br /> CITY �- rt, STATE ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 19881989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX xxxx 5 <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multip(y # by fee for <br /> A each year applicable) 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx S <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minirmm/TANK) # TANK(s)_ X $234.00 = 5 <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <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 = 578.00/hour (3 hours mininun/FACILITY) = $234.00 mini mum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hrSAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL DUE 5 - <br /> FOR OFFICE USE ONLY <br /> :::.:::::::..::::::::.!:::::::::[[F::--:::::::::: :::::•...:--;F :-v iii iiiii _5iii[i[i_is;:::_:_: e3eiei-_F::;_:°J;"+_' ::::;;:'eam__:-;:_:i3e-i:[[secte_�_;::er_a_:i::___;:_e_:mee_-ee34ii��__:_ :_m:mna <br /> iis__:::::::::��::ii:ie <br /> SWEEPS # ,COMPUTE LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH Up <br /> RECEIVED BY DATE RECEIVED <br /> _ __ _ <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />