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SAN JOAQUIN ' 'TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HF'LTH DIVISION <br /> UI ROUND STORAGE TANK PROGRAM - FEE WORKSHEE' <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 2-11 <br /> T <br /> E fACILITY ADDRESS .ST ,2 <br /> S �NE # with CODE 1�� <br /> CITY STATE ZIP CODE # of TANKS <br /> A �it�lL�� //.� C SJ� at SITE 3 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS AP LICANT PHONE # 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 S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = -:3� 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <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 STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks_'j_ $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <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 & Inspections) TANK I.D. #(s) <br /> 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 _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 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 S Z <br /> FOR OFFICE USE ONLY <br /> __..—:-....:.—:— .__ ._._;._...._.._._........................_._......__._..............._.._.._...._ <br /> _ _._.�.__._.._ _.� _ <br /> _ SWEEPS # COMPUTER # _LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK #/CASH I RECEIVED BY DATE RECEIVED " <br /> s <br /> $ = <br /> 9 <br />