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.3-17-1999 9:40Atl FPOM P. 9
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - £NVIROWENTAL HEALTH DIVSION
<br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET
<br /> S FACILITY SITE NAME FACILITY CONTACT NAME
<br /> ME
<br /> f
<br /> T'
<br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE
<br /> CITY j STATE ZIP CODE # of TANKS
<br /> A - L ft- so-E at Si TE
<br /> P-
<br /> PI APPLICANT/BILLING NAME APPI.l�ANT NTACT AME
<br /> I co v t ti
<br /> C MAILING ADDRESS I APPLICANT PHONE # WITH AREA CODE
<br /> NTD k CDle ek
<br /> T CITY STATEZIP CODE TYPE of APPLICATION
<br /> �Ol.,ltCoir f � (Closure, Installation, etc.) t
<br /> TOTAL
<br /> 1986 1987 1988 1989 i 199tl
<br /> ANNUAL FACILITY PEE (Prior to January 1, 1491) _ S100.00
<br /> A XXXX ! XXXX XXXX f Xxxx XXXX $ XXXXXxxx
<br /> e ,
<br /> T FACILITY PENALTY FEES ASSESSED (If AppLicable) I XXXXXXXX ( XXXX XXXX XXxx 3 XXXXXXXX
<br /> I� I
<br /> Yi TANK FEE _ $50.00/TANK (Prior to January 1,1491) i 5170/TANK (Atter January 1, 1991)
<br /> E
<br /> Tanks = 11988 1 1989 1 1990 1991 1992 1993 1994 11995 11996 i 1997 1998
<br /> F (multiply # by fte for I
<br /> Al each year applicable) xxx Xxxx XXXX
<br /> XXXX XXXXX S
<br /> I c`
<br /> I TANK PENALTY FEES ASSESSED I xxxX XXXX Xxxx XXXX (XXXX I I I , $
<br /> L J
<br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 S
<br /> T
<br /> Y # Tanks x 58.00 1988 through 1993 ($56) '993 through 1997 C$S6), 1998
<br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S
<br /> C� PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. 0(3)
<br /> S! CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) I 0 TANK(s) x $234.00 3
<br /> Ul TEMPORARY CLOSURE (Plan Review & Inspections) i TANK I.D. #(s)
<br /> Rl
<br /> EI TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $
<br /> I
<br /> LI INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s)
<br /> Al
<br /> NI PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $
<br /> EiREPAIR FEE (Workplan Review s Construction Inspections) TANK I.D. 4(s)
<br /> P TANK LINING REPAIR FEE m $78_00/hour (3 hours minimum/TANK) I 9 TANK(s) X $234.00 $
<br /> A r
<br /> I TANK RETROFIT REPAIR FES - 578.00/hour (3 hours min./FACILITY) _ $234.00 minimum I $
<br /> R
<br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum I $
<br /> Mi TRANSFER FEE = S20.00 ' UNAUTHORIZED RELEASE EVALUATION _ S78.00/hr 3
<br /> SI I ! 1
<br /> C CONSULTATION FEE _ $78.00/hr i SAMPLING INSPECTION "r_E = 378.001hr i S
<br /> TOTAL DUE S
<br /> FOR OFFICE USE ONLY
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<br /> SWEEPS # I COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK C./CASH RECEIVED SY ` DATE RECEIVED
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