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SAN JDAOUIN COUNTY PUBLIC HEALTH SERVICES - ElNIRCHMENTAL HEALTH OIVSION <br /> UND' 011lm STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME I FACILITY CCNTACT NAME <br /> I <br /> T I SITE PHONE + with AREA CODE <br /> "E FACILITY ADDRESS <br /> i I f�TATEI Ztp C�^D I x of TANKS <br /> CITY IIIIITT 5 r. at SITE <br /> A <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I APPLICANT PHONE "- WITH AREA CODE <br /> C NAILING ADDRESS <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY (Clasure, Installation, eta.) <br /> TOTAL <br /> 1986 11987 11988 11989 11990 <br /> A <br /> ANNUAL FACILITY FEE (Prior :o January 1, 1991) = 5100.00 xxxx Ixxxx I xxxx XIDEX I XXX% S XXXXXXXX <br /> C I XXXX I XXXX I %XXX I XXXX I X%%X 5 xxxxxxxX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> II 5170/TANK (After January 1, 1991) <br /> v TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E <br /> I Tanks = 1988 1989 11990 11997 11992 11993 11994 11995 11996 11997 11998 <br /> f (multiply by tee for S <br /> A each year appLicable) %%XX I %%%X I XXXX I %XXX IxxxX <br /> C <br /> [ TANK PENALTY FEES ASSESSED I xxxx I xxxx I xxxx I xxxx Ixxxx <br /> I ( I I I S <br /> L S <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=S18.50 <br /> T <br /> T N Tanks_ x58.00 1988 through 1993 (SSb) 1993 through 2997 (556)+ 1998 <br /> SURCHARGE FOR 1998 I xXXXXXXXXXxXXXXX%XXXXX%XX%X X%XXXXX%XXXXX%XXXX%XXXX I I S <br /> CI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK C.D. d(s) n <br /> L iANK(s)_� X 5234.00 = I i Z} <br /> OI CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> STANK I.O. d(s) <br /> UF TEMPORARY CLOSURE (Plan Review 3 inspections) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 mini mum S <br /> PI INSTALLATION PLAN CHECK (Plan Review 3 Construction [nspections)I TANK 1.0. w+(s) <br /> L <br /> A5 <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 miniaam <br /> R REPAIR FEE (Workplan Review 3 Construction Inspections) I TANK (.D. i(s) <br /> EI i <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I % TANK(s) _ X 5234-00 = <br /> Ahaus min./FACILITY) 5234.00 mini <br /> I S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 nam <br /> RI S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = 5234.00 minimum <br /> MI TRANSFER FEE = 520.00 I I UNAUTHORIZED RELEASEE EVALUATION = 578.00/hr I I I S <br /> II I I I <br /> S I S <br /> C CONSULTATION FEE = 578.00/hr I I SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE S &O <br /> FOR OFFICE USE ONLY --_= <br /> 54EEP5 3T COMPUTER x I LOC CODE I GIST CODE I AMOUNT RECEIVED I CHECK WCASH I RFEZ to dT I GATE 7ECCIVEO <br /> EH 23 032 (REVISED 1-12-98) <br />