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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION
<br /> UNDERGROUND STORAGE TANK PROGRAM - FEE UORKSHEET
<br /> S FACILITY SITE NAME C FACILITY CONTACT NAME
<br /> I J
<br /> T
<br /> E FACILITY ADDRESS (( � SITE PHONE # with AREA CODE
<br /> i 12 qQ I e, l..Ot�tSF
<br /> CITY STATE IF CODE # of TANKS
<br /> A Cr!' 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 STATE ZIP CODE TYPE of APPLICATION
<br /> T CITY
<br /> (Closure, Installation, etc.)
<br /> TOTAL
<br /> 1986 1987 1988 1989 1990
<br /> byear
<br /> L FACILITY FEE (Prior to January 1, 1991) = $100.00 ;
<br /> xxxx xxxx xxxx xxxx XXXX
<br /> LITY PENALTY FEES ASSESSED (If Applicable) X%%X xxxx xxxx xxxx xxxx
<br /> I
<br /> FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) Tnsd�03
<br /> nks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
<br /> tiply # by fee for
<br /> year applicable) xxxx xxxx XXXX XXXX %%%% I✓/ .Pl ado 8�00
<br /> PENALTY FEES ASSESSED xXx% XXXX x%%X X%xx XXXX ~ 7O 1 dl KEE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287nks I x 556.00 1988 through 1990 199trough 1996
<br /> er amount and year)
<br /> � o
<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 5234.00 = f
<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 minimum/FACILITY) $234.00 minimum 1
<br /> P INSTALLATION PLAN CHECK (Plan Review 6 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 $234.00 S
<br /> A
<br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 1234.00 minimus 1
<br /> R
<br /> PIPING REPAIR FEE = E78.O0/hour (3 hours minimus/FACILITY) 1234.00 minimum 5
<br /> N TRANSFER FEE = 120.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr S
<br /> I
<br /> S
<br /> C CONSULTATION FEE 578.00/hr SAMPLING INSPECTION FEE - 578.00/hr 5
<br /> TOTAL DUE S
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<br /> SWEEPS # I COMPUTER # LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/CASH RECEIVED 8Y I DATE RECEIVED I
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