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SAN JOAQUIN COUNTT PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UW ' JO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAMEFACILITY CONTACT NAME <br /> I I <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> d <br /> CITY 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, iru tallati on, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A 5 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) )000( =C( 5 <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After Jan ry 11 1991) <br /> E <br /> 4 Tanks 1986 1987 1988 1 1989 1990 1991 1992 1993 1994 1995 1 1996 <br /> F (multiply <br /> Tvfee for <br /> A each year applicable) 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED )0= xXxX S <br /> L <br /> I STATE SURCHARGE - 256.00 each TANK (Due every 5 years) See California H & S Code, Section 25267 <br /> T <br /> Y # Tanks_ x 556.00 1986 through 1990 1991 through 1996 <br /> r) <br /> (Enter amount and Yea <br /> 1 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE - S78.00/hour (3 hours minimm/TANK) # TAN <br /> X 1234.00 = 1 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minima /TANK) # TANK(s)_ X 5234.00 5 <br /> P (NSTALLATiON PLAN CHECK (Plan Review & Construction Inspectiore) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE . 578.00/hour (8 hours minimum/FACILITY) $624.00 minims S <br /> R REPAIR FEE (Workplan Review & COnStrUCtion Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE 578.00/hour (3 hours mini mum/TANK) # TANK(a) __ X 2234.00 • S <br /> A S <br /> 1 TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) 5234.00 minimum <br /> R S <br /> PIPING REPAIR FEE 578.00lhour (3 hours miniaaan/FACILITY) 5234.00 minimum <br /> M TRANSFER FEE • 520.00 UNAUTHORIZED RELEASE EVALUATION • 578.00/hr S <br /> 1 <br /> S . 578.00/hr S <br /> C CONSULTATION FEE • 578.00/hr SAMPLING INSPECTION FEE <br /> lE E <br /> TOTAL DUE 1 <br /> FOR OFFICE USE ONLY -- <br /> a <br /> SWEEPS # I COMPUTER Al I LOC CODE DIST CODE AMCUNT RECEIVED CHECK #/CASH RECEIVED BY GATE RECEIVED <br /> _ 3 <br /> 3 5 <br /> EH 23 032 (REVISED 11.1.92) Page 11 <br />