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• SAN JOAQUNTY PUBLIC HEALTH SERVICES - ENVIRONMENT A LTH DIVISION <br /> RGROUND STORAGE TANK PROGRAM - FEE WORKSHE <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T Y <br /> E FACILITY ADDRESS SIT PHONE # with AREA CODE <br /> o zO9 - 4/z,-A- 870 I <br /> CITY 1 ST TE ZIP CODE # of TANKS <br /> P -! Qc k -t•0 h 2r at SITE 3 <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Lc <br /> I <br /> C MAILING AD RESS APP ICANT PHONE # WITH AREA CODE <br /> " <br /> N 4015 F: 0 . o - 4 62 - 8 O <br /> T CITY ._J_ STATE ZIP CODE TYPE of APPLICATION <br /> S 1 OC o n (CLosure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 8100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X%XX XX%% X%%X XXXX XXXX S XXXXXXXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1 1988 1989 1990 1991 1992 1993 1 1994 1 1995 1996 <br /> F (multiply # by fee for <br /> A each year appLicable) XXX% XXXX X%XX XX%X XX%% $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXXXXXX XXXX X%XX XXXX S <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> amount ount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 8234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours mini mum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION 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) = 8624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 878.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = 8 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 878.00/hour (3 hours min./FACILITY) = $234.00 minimum 8 <br /> R <br /> PIPING REPAIR FEE = 878.00/hour (3 hours mini mum/FACILITY) = 8234.00 minimum S <br /> M TRANSFER FEE = 820.00 UNAUTHORIZED RELEASE EVALUATION = 878.00/hr $ <br /> 1 <br /> S <br /> C CONSULTATION FEE = 878.00/hr SAMPLING INSPECTION FEE = 578.00/hr 8 <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> .._....:::::....:::......................................_..........:.............:....... .......................................................;............,...::.::::::::.:::::::::.:::::::::: ::::::..................._.___.__..........................._...........................................................;.............................. <br /> m .a......_.::_:::::u::=_�................................................... �[:___................:::::::::::::::::::::t:::::::-:::::;::::[[[[[m[[[[[m_-[_:::c::� <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> S <br /> :. ._...._.....................__.........____ <br /> ...................................._..... _:-_:-::.—..........,... ...... <br /> ..........................................................................._................._.____ ................._.............__..........................................._.........._... ............................................................... <br /> ............................................................................_..._.....:::_._..__ ..__.....___.... ...._.. _.... .......... .............. <br /> 9 <br />