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x-17-1999 9:4@AM FROP" P_ 9
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION
<br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET
<br /> S FACILITY SITE NAME FACILITY CONTACT NAME
<br /> I
<br /> T
<br /> "E FACILITY ADDRESS SITE PHONE # with AREA CODE
<br /> & C,0• :10 (0 V&
<br /> CITY STATE ZIP CODE # of TANK5
<br /> P � 1S�j. CtfyoS at SITE 3
<br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME "
<br /> L
<br /> I
<br /> C MAILING ADDRESS APPLICANT PHONES # WITH AREA CODE
<br /> T CITY STATE ZIP CODE 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 $ XXXXXxxx
<br /> C
<br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXxx XXXX XXxx XXXX S XXXXXxxx
<br />{ I
<br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991)
<br /> E
<br /> # Tanks = 1988 1989 1990 1 1991 1992 1993 1994 1995 1996 1997 1998
<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 I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 $
<br /> T
<br /> Y 9 Tanks x $8.00 1988 through 1993 ($56) 1993 through 1997 (S56) 1998
<br /> SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx $
<br />'r
<br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s)
<br /> L
<br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $
<br /> S
<br /> U TEMPORARY CLOSURE (Plan Review iL Inspections) TANK I.D. #(s)
<br /> r R
<br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/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 = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $
<br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s)
<br /> E
<br /> P TANK LINING REPAIR FEE a $78.00/hour (3 hours minimum/TANK) it TANK(s) _ X $234.00 ' $
<br /> A
<br /> I TANK RETROFIT REPAIR FEE - $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $
<br /> R
<br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $Z34.00 minimum $
<br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $
<br /> I
<br /> S
<br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78_00/hr S
<br /> TOTAL DUE $
<br /> FOR OFFICE USE ONLY
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<br /> $WEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK 0/CASH RECEIVED SY DATE RECEIVED
<br /> $
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