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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S! r 1, ITY SITE NAME j �� I TYl CONTACT NAME <br /> EI FAC LI TY ADDRESS � SITE PH E with AREA CODE <br /> I ' /S-PATE <br /> (j'J P_CODE : of TANKS o <br /> at SITE R <br /> PI AP. 1C TY L' A,LI NT C019ACT NAME c <br /> I <br /> C! MAILING ADDRESS I APPLICANT PHONE WITH AREA CODE <br /> Al - - — <br /> T I �ATEI ZI C E TYPE of APPLICATION <br /> Jo �� I (J I (Closure, Installation, etc.) <br /> TOTAL <br /> 1 11986 1987 1 1988 1989 1 1990 <br /> E j ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> i I <br /> AI I XXXX I XXXX I XXXX 1 XXXX XXXX $ XXXXXXXX <br /> S C i <br /> I <br /> TFACIL'TY PENALTY FEES ASSESSED (If Apoticable) XXXX XXXX XXXX XXXX I XXXX S XXXXXXXX <br /> i I <br /> V' TANK FEE = S50.00/TANK (Prior to January 1,1991) ; 5170/7ANK (After January i, 1991) <br /> 6 _ <br /> 1987 1988 11989 i 1990 1991 i 1992 1993 1994 1995 1996 j 1997 <br /> E 'r! (multipty a by fee for <br /> y A; eecn year aoplicabte) XXXX XXXX XXXX I XXXX !XXXX j I S i <br /> I; TANK PENALTY FEES ASSESSED XXXX I XXXX XXXX I XXXX !XXXX i 6 S <br /> E L <br /> Ij STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 Is <br /> T' r <br /> 7i Tanks x 58.00 1988 through 1990 (S56) 1991 througn 1996 (S56)1 1997 <br /> SURCHARGE FOR 1997 I XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. R(S) <br /> L <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) i 7ANK(s) X S234.00 5 <br /> S' <br /> UI TEMPORARY CLOSURE (Plan Review & inspections) I TANK I.D. :(s) <br /> R' i <br /> I E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S S <br /> P! INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. T(s) <br /> Al <br /> Y <br /> NI PLAN CHECK F'c_ = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S � <br /> RREPAIR FEE (Uorkp(an Review & Construction Inspections) i TANK I.D. �(s) <br /> E <br /> P! TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X S234.00 = S <br /> A <br /> II TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S 1 O� <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> MI TRANSFER FEE = S20.00 I I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I S <br /> SI I I I <br /> C! CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = S78.00/hr I I S <br /> TOTAL DUE S o2 3 , m b <br /> FOR OFFICE USE ONLY <br /> SWEEPS 4 I COMPUTER 1! I LOC CODE I DIST CODE I AMOUNT RECEIVED � CHECK #/CASH I RECEIVED 3Y I DATE RECEIVED <br /> EH 23 032 IRFVtSFn S-77-07N <br />