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ANNUAL FACILITY FEE (Prior <br />' <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - <br />ENVIRONMGNTAL HEALTH DIVSION <br />_ <br />1988 <br />UNDERGROUND STORAGE TANK PROGRAM - FEE :SHEET <br />S <br />FACILITY SITE NAME <br />�../ <br />I <br />SCL <br />II <br />Ul TEMPORARY <br />a TANK(s)% <br />FACIL jX CONTACT NAME <br />T <br />nov r li ` _ rt <br />E <br />FACILITY ADDRESS <br />J <br />E� TEMPORARY CLOSURE FEE - $78.00;hour (3 hours minimm/TgNK) <br />s <br />T FACILITY PENALTY FEES ASSESSED (If <br />Applicable) <br />X <br />SITE PHONE # with AREA CODE <br />P INSTALLATION PLAN CHECK (Plan Review 8 Construction ins <br />I <br />TANK I.D. #(s) <br />CITY <br />A <br />x%X% <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours m inimun/FACILITY) <br />STATE ZIP <br />CODE # of TANKS <br />P <br />- t din <br />S <br />'Z I at SITE ' <br />P <br />A LICANT/BILLING NAME <br />E <br />E <br />L <br />PI TANKLINING REPAIR FEE = S78.00/hour (3 L•curS min irtm/TANK) <br />M1 ( <br />-ANK(s) <br />APtCANT CON Ty1CT`NAME <br />ci'c-ocT <br />I <br />January <br />1, 1991) <br />i 1� 4®u <br />C <br />MAILING ADDRESS <br />11189 1990 <br />L <br />199 1 1992 <br />A <br />1994 <br />(. <br />APPLICANT PHONE # WITH AREA CODE <br />minimus <br />S <br />`l IG^-37Z-`� <br />T <br />CI Y <br />C <br />C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE <br />ZIP <br />CODE TYPE of APPLICATION <br />= S78.00/hr <br />r <br />RSTATE <br />`-fa <br />I <br />6C (Closure, Installation, etc.) <br />XXx% <br />%xx% <br />TOTAL <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) = <br />S100.00 <br />1986 <br />1987 <br />1988 <br />1989. 1990 <br />A <br />_I <br />DOSURE FEE = S78.00/hour (3 hours minir�m/LANK) <br />SCL <br />II <br />Ul TEMPORARY <br />a TANK(s)% <br />_ <br />5234.00 ; . <br />C <br />R` <br />LANK I.D. N(5) <br />J <br />E� TEMPORARY CLOSURE FEE - $78.00;hour (3 hours minimm/TgNK) <br />s <br />T FACILITY PENALTY FEES ASSESSED (If <br />Applicable) <br />X <br />S234.00 = S <br />P INSTALLATION PLAN CHECK (Plan Review 8 Construction ins <br />I <br />TANK I.D. #(s) <br />A <br />x%X% <br />%X%x <br />N PLAN CHECK FEE = S78.00/hour (8 hours m inimun/FACILITY) <br />5 <br />V TANK FEE = S50.00/TANK <br />(Prior <br />to January 1,1991) <br />S <br />R[ REPAIR FEE (Workplan Review 8 Construction Inspections) <br />E <br />E <br />PI TANKLINING REPAIR FEE = S78.00/hour (3 L•curS min irtm/TANK) <br />M1 ( <br />-ANK(s) <br />5170/TANK <br />(After <br />January <br />1, 1991) <br /># Tanks = <br />F (multiply # by fee for <br />1986 <br />1987 1989 <br />11189 1990 <br />L <br />199 1 1992 <br />1993 <br />1994 <br />7995 1996 <br />A each year applicable) <br />minimus <br />S <br />M 00/lir <br />TRANSFER FEE - S20.00 UNAUTHORIZED RELEASE EVALUATION = S78. <br />I <br />S <br />C <br />C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE <br />= S78.00/hr <br />S <br />I [AHK PENALTY FEES ASSESSED <br />XXx% <br />%xx% <br />L <br />/CASII RECEIVED—ST-1- <br />i <br />I STATE SURCHARGE = S56.00 each TANK <br />i <br />(Due every 5 <br />years) See California <br />S <br />H 8 S <br />Code, <br />Section <br />25287 <br />yl# Tonks_ x $56.00 <br />1986 thrcugh <br />1990 <br />(Enter amount and year) <br />14:1 <br />through <br />1996 <br />S <br />C PERMANENT CLOSURE (Removal or Authorized Closure. <br />TANK I.D. N(s) <br />_I <br />DOSURE FEE = S78.00/hour (3 hours minir�m/LANK) <br />SCL <br />II <br />Ul TEMPORARY <br />a TANK(s)% <br />_ <br />5234.00 ; . <br />CLOSURE (Plan Review & Inspections) I <br />R` <br />LANK I.D. N(5) <br />J <br />E� TEMPORARY CLOSURE FEE - $78.00;hour (3 hours minimm/TgNK) <br /># iANK(s) <br />X <br />S234.00 = S <br />P INSTALLATION PLAN CHECK (Plan Review 8 Construction ins <br />pe[tion5)' <br />TANK I.D. #(s) <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours m inimun/FACILITY) <br />= S624.00 minimus <br />S <br />R[ REPAIR FEE (Workplan Review 8 Construction Inspections) <br />E <br />TAN( I.D. #(s) <br />PI TANKLINING REPAIR FEE = S78.00/hour (3 L•curS min irtm/TANK) <br />M1 ( <br />-ANK(s) <br />% <br />8234,00 = ; <br />I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />R. <br />= S23400 <br />minimum <br />8 <br />PIPINC REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= S234.00 <br />minimus <br />S <br />M 00/lir <br />TRANSFER FEE - S20.00 UNAUTHORIZED RELEASE EVALUATION = S78. <br />I <br />S <br />S <br />C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE <br />= S78.00/hr <br />S <br />TOTAL DUE S 2 J <br />Nt OFFICE USE ONLY <br />SWEEPS # I COMPUTER # I LOC CODE I DIST CODEn u <br />I AMOUNT REC <br />CEI CHH <br />/CASII RECEIVED—ST-1- <br />DATE RECEIV <br />EH 23 032 (REVISED 11-1-92) Pnge 11 <br />