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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRON ENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE uORXSHEET <br /> S FACILITY SITE NAME <br /> I FACILITY CONTACT NAME <br /> T <br /> E ?FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> �.� sacd4hr 7-d �Y STATE ZIP CODE # of TANKS <br /> A <br /> at SITE <br /> P. <br /> P APPLICANT/BILLING NAME <br /> L APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS I <br /> A APPLICANT PHONE # WITH AREA CODE <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 11987 11988 119891990 <br /> C <br /> XXXX XXX% XXXXAl XXXX XXXX 5 XXX%XXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I X%XX XXXX I XXXX I XXXX XXXX S XXX%XXXX <br /> VI TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) 4—, 17 <br /> E ��� <br /> Tanks = ( 1987 1988 11989 11990 11991 1992 11993 11994 11995 11996 11997 <br /> F (muttiply # by fee for <br /> Ceach year applicable) XXXX I XXXX I X%XX I XXX% I%XXX 71-70T/70 I (7o I170 1 /70 I17O g <br /> I TANK PENALTY FEES ASSESSED XXXX %XXX XXXX XXXX X%XX / I - <br /> L' 5 oa(4 x9 <br /> II STATE SURCHARGE FOR NEW FACILITIES ONLY = 518-50 I5 1 8 St7 T✓ <br /> T Dol (J <br /> Y # Tanks I x $8.00 1988 through 1990 (556) 1991 through 1996 ($56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXX%XXXX%%% XXXXXXXXXXXXXXXX%XXXXXX g.civ <br /> D fl <br /> Cl 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) 5234.00 = g <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. #(s) <br /> R <br /> El TEMPORARY CLOSURE FEE = S78-00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> PINSTALLATION PLAN CHECK (Plan Review & 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 g <br /> R REPAIR FEE (Workp(an Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234,00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234-00 mini mum g <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minima/FACILITY) = 5234-00 minimum <br /> S <br /> M TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> I S <br /> S <br /> Cl CONSULTATION FEE = 578,00/hr <br /> SAMPLING INSPECTION FEE = 578.00/hr I I g <br /> TOTAL DUE S Z OGo•50 <br /> FOR OFFICE USE ONLY <br /> SWEEPS # I COMPUTER # LOC CODE DIST CODE AMOUNT <br /> RECEIVED CHECK #/CASH I RECEIVED By DATE�RE <br /> EiVED <br /> S <br /> EH 23 032 (REVISED 5-27-97) <br />