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SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH OIVSION <br /> Uxogep= STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T I SITE PHONE 9 with AREA CODE <br /> "E FACILITY ADDRESS <br /> & CITY STATE ZIP CCOE 3 of TANKS <br /> A at SITE <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I APPLICANT PHONE F WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY <br /> (Closure, [nstallati on, etc-) <br /> TOTAL <br /> 1986 i 1987 1988 1989 7990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 XXXX XXXX XXXX xxxx XXXX S XXXXXXXX <br /> A <br /> CXXXX I XXXX %)(XX XXXX I %X%X 5 XXXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) 71ua <br /> E <br /> Tanks = 7988 11989 1990 1991 1992 17993 I�1994 11995 1996 1 ,1997 1998 <br /> F (multiply X by fee for v Sc> L, o 5 <br /> A each year applicab(e) XXXX %XXX I XXXX XXXX IXX%X I I I ` <br /> Ci b KO V 0 <br /> [ TANK PENALTY FEES ASSESSED I XXXX I XXXX %XXX XXXX (XXXX <br /> L S <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY--$18.50 ���la H ,g <br /> T <br /> Y : Tanks* x 58.00 1988 through 1993 (S56) 1993 through 1997 (556) 1998 <br /> G,l rrga <br /> SURCHARGE FOR 1998 I XXXXXXXXXXXXXXXXXXXXXX%XXXX XXXXXXXXXXXXXXXXXXXXXXX S PaA <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK LD. X(s) <br /> L TANK(s) X 1234.00 = S <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. t(5) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimuP/FACILITY) 5234.00 minimm S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. S(s) <br /> L <br /> A5 <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimum <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.O. N(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) X TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R5 <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = 5234.00 minimum <br /> H� TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASEE EVALUATION = 578.00/hr I S <br /> I I I I <br /> S' <br /> L CONSULTATION FEE = $78.00/hr I SAMPLING (NSPECTICN FEE = 578.00/hr S LT Te <J <br /> TOTAL DUE S— <br /> FOR OFFICE USE ONLY _ -_---- <br /> -____ _ _ - _ ____—_ =--Y DATE RECEIVED <br /> :::.. .....E ..:._.._:::ttt::::: .. .. <br /> _ SWEEPS S COMPUTER N LOC CODE DIST CODE AMOUNT RECEIVED I CHECK */CASH I RECEIVED B <br /> EH 23 032 (REVISED 1-12-98) • . <br />