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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAT_TH DIVISION UND" IND STORAGE TANK PROGRAM - FEE WORKSHEET S FACILITY SITE NAME FACILITY CONTACT NAME T / 1989 1990 CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ E FACILITY ADDRE S SI PHONE with AREA CODE & 40 (-l'!�' / 0cC sfW -33`f— d-27 XXXX XXXX XXXX XXXX XXXX CITY STATE ZIP CODE (�' # of TANKS SITE FR%�/ R S at $234.00 minimum $ C P L? APPLIC!IT/BILLING NAME Coil APPLIC T CONTACT NAME 4i C` -)r -e-1 T FACILITY PENALTY FEES AS;ESSED (If Applicable) C MAILING ADDRESS APPLICANT PHO4 WITH AREA CODE 0% ) N XXXX 33,(- 0,5P z 1- T CITY STATE ZIP CODE TYPE of APPLICATION L(9cGt ' alf ry f -a yr (Closure, Installation, etc.) TOTAL C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) 1986 1987 1988 1989 1990 CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ # TANK(s) X $234.00 = $ S XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX A $ R R E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ C T FACILITY PENALTY FEES AS;ESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX I V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 F (multiply # by fee for XXXX XXXX XXXX XXXX XXXX $ A each year applicable) C I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ L I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 T Y # Tanks x $56.00 1988 through 1990 1991 through 1996 (Enter amount and year) $ C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) I AMOUNT RECEIVED CHECK #/CASH L CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ # TANK(s) X $234.00 = $ S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ R R E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) I AMOUNT RECEIVED CHECK #/CASH L CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ A N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) I AMOUNT RECEIVED CHECK #/CASH E CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ TOTAL DUE $ < P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ R PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ I AMOUNT RECEIVED CHECK #/CASH S C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ TOTAL DUE $ < FOR OFFICE USE ONLY SWEEPS # COMPUTER # LOC CODE ::::::::::::::::::::::::::::::::::::::::::::a:::::::::::::::::::::::::::::::::::;::::s:::ss DIST CODE AMOUNT RECEIVED CHECK #/CASH ::::;::::::s::::::::::::t::::::::::::::::::::::::::::s:::s:::s::s:::::::::•:::•:::::::::::::::::::::::::::::::::::::::::: RECEIVED BY DATE RECEIVED