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• SAN JOAQUIN COUNTY vLIC HEALTH SERVICES - ENVIRONMENTAL HEALTI. 'SION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE UORKSHEET <br /> S. FACILITY ITE NAME FACILITY CONTA AME <br /> I <br /> T <br /> 'E F CIM Y ADDRESS ^V� SITE PHONE 9 with AREA CODE <br /> 8 ` <br /> CITY STATE IP CODE X of TANKS <br /> A at SITE <br /> P lei�J <br /> P APP (CANT/BILLI N E A CANT CT NAME <br /> L <br /> I <br /> C M LING ADDR S AP CANT PHONE � WI AREA CODE <br /> A t �, ZJ I—�l <br /> W, 222D <br /> TI CIM I .STA <br /> TETYPE of APPLICATION <br /> O ( osure Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A xxxx XXXX I XXXX I XXXX XXXX S xXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXxx XXXX XXXX XXXX XXXX $ xxxxxxxX <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E <br /> X Tanks = 1988 1989 11990 1991 11992 1993 11994 11995 11996 11997 11998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX I XXXX I XXXX XXXX I I I S <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX XXXX I XXXX IXXXx I I I I ` S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T <br /> Y # Tanks x $8.00 1988 through 1993 ($56) 1993 through 1997 (556) 1998 <br /> SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxXXX XXxxxxxxxXXxxxxxxxXXXxX S <br /> C PERMANENT CLOSURE (Removal or Authorized Ciosure-in-Place) I TANK I.D. ;*(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I a TANK(s) X S234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK 1.0. ;*(s) <br /> R <br /> E� TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections)I TANK I.D. 4(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. 0(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) X TANK(s) X S234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $734.00 minimum 5 <br /> N TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I { <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> SWEEPS COMPUTER x LOC CODE DIST CODE I AMOUNT RECEIVED 1 CHECK ;*/CASH RECEIVED BY OATE RECE?VED <br /> __._....._......-....._ ................................... <br /> -- _!.._._.._-.--._.._._ <br />