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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br />U:' 'ROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />�S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />T <br />t= C <br />.M 9 12 — z l (ZK L t✓ <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />P <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />5 <br />A <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />P <br />T �!}C. t <br />L 7} <br />�5��� <br />at SITE <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum $ <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />1 <br />5 <br />C <br />MAILING ADDRESS <br />APPL CANT PHONE # WITH AREA CODE <br />A <br />N <br />(> 7 ' CT <br />� 1.3, <br />T <br />CITY <br />V Ll Egl t VV <br />STATE <br />(' f} <br />ZIP CODE <br />jt -/5 L f <br />TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />1986 1987 1988 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />A XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br />C <br />TFACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX 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 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />F (multiply # by fee for <br />A each year applicable) XXXX XXXX XXXX XXXX XXXX $ <br />C <br />I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ <br />L <br />I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br />(Enter amount and year) <br />$ <br />C <br />PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) <br />TANK I.D. #(s) <br />DIST CODE <br />AMOUNT RECEIVED <br />I CHECK #/CASH <br />L <br />DATE RECEIVED <br />P <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />5 <br />A <br />S <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum $ <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum $ <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />5 <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />L <br />A <br />N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />TANK I.D. #(s) <br />= $624.00 minimum <br />5 <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />DIST CODE <br />AMOUNT RECEIVED <br />I CHECK #/CASH <br />E <br />DATE RECEIVED <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = $ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum $ <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum $ <br />M TRANSFER FEE = $20.00 <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr <br />FOR OFFTCF USF ONIY <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />S <br />TOTAL DUE Y S <br />SWEEPS # <br />COMPUTER # <br />LOC CODE <br />DIST CODE <br />AMOUNT RECEIVED <br />I CHECK #/CASH <br />RECEIVED BY <br />DATE RECEIVED <br />5 <br />