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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIROMIENTAL °'ALTH DIVISION <br /> UI (ROUND STORAGE TANK PROGRAM - FEE WORKSHEE <br /> S FA LITY TE NAME FACILITY CONTACT NAME <br /> I AtLL <br /> T <br /> E FACILITY DRESSSITE PHONE # with AREA CODE <br /> /7 S �1, /17 f G�, r <br /> iv <br /> CITY 0 STATE 21P LODE # of TANKS 7 <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 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XX%X %XX% %XXX XXXX XXXX S XXXX%XXXXXX%X <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) Xx%X XXXX XXXX XXXX XXXX f X100(%XXXXXXXX <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 7 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 ;Z3.G 6 N� <br /> F (multiply # by fee for L <br /> A each year applicable) Xx%X X%%X XXX% XXXX XXXX 179-r 6 I 170. $ 34 O. 2 <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXX xxxX Xxxx I 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_,a_ x $56.00 1988 through 1990 1991 through 1996 .1nN 0,76 L <br /> (Enter amount and year) / <br /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = $ <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 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimm/FACILITY) _ $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANKI.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimm/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr f <br /> TOTAL <br /> FOR OFFICE USE ONLY <br /> .........__...__......_............................_.............._...___._._......_._.... .::::-: :.—_:__ : —.-!!m'!!=!;___.,:.--::::::::_::::::___:::_._._— <br /> ........................_........................................_......._.._....._......................... . .......—_................_._...._...___..__....._..._.........._........._........_...__..._.. <br /> :::: ... ...... .... <br /> SWEEPS # I COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> id 8 <br /> ..... ..... ..-. . ... . . . . .._.�.::.::. ._:........._....__...—a.�._......__...�::_::_...._.._..__ <br />