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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DiVS10N <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> E FACILITY ADDRESS SITE PHONE * with AREA CODE <br /> CiTY STATE ZiP CODE X of TANKS <br /> Ai�?itJ'—tsIf 4 - �-" at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> C MAILING ADDRESS A iCANT PHONE 0 WITH AREA CODE <br /> W <br /> T CITY STATE ZIP CODE TYPE of APPLiCAT <br /> (Closure, , stal lation etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) XXXX XXXX f <br /> 1 <br /> V TANK FEE _ %50.00/TANK (Prior to January 1,1991) 1170/TANK (After January 1, 1991) <br /> E <br /> 4 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) f <br /> C --- <br /> 1 TANK PENALTY FEES ASSESSED 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 M Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(s) <br /> L -- <br /> 0 CLOSURE FEE _ %78.00/hour (3 hours minimum/TANK) N TANK(s) X $234.00 - f <br /> S - <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE _ 978.00/hour (3 hours minimum/TANK) IY TANK(s) X $234.00 = % <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 f <br /> R REPAIR FEE (Workplan Review 8 Construction inspections) TANK I.D. IN(s) <br /> E <br /> P TANK LiNING REPAIR FEE _ $78.00/hour (3 hours minirmwn/TANK) 0 TANK(s) X !234.00 = f <br /> A -- <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum f <br /> R --- <br /> PiPiNG REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) a $234.00 minimL n f <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr % <br /> -- <br /> S- <br /> C CONSULTATION FEE _ %78.00/hr SAMPLING INSPECTION FEE = $78.00/hr f <br /> TOTAL DUE 3 <br /> FOR OFFICE USE ONLY <br /> !EiEE?ii?iin!i!ii',Iimi1!n°IIIH I:iI!!mlll!ii!in�t�tI !m 'i??!ii nn 'nAG :iii!!+ :! t? 19!Ini?ttP.i!'.iiltt'nl!Iii lttim :.!!ttnintnflnilim"Jit?^-!rat?ntnnniniliinnnni.'!nR!!!•+iminn!!!n!iix!ntn!m nlnlNltiniiiit!n;i!liililitinniiitti!HI Ittlnnn!!Iliiii!i!IN!11I <br /> Ig ..... ....... . . .l....• .. .. . <br /> :::::...................nr:::r.:{� :a•:rn :•e:r.::rc+s•:r n ee•:'Ii•a^r.:�i::: e:.j:�n:mp.�n••Mi.�{u :!::u::rr::rr.:f•: {�:r. •:a:. n :ai....:. m n::::u.:......m::•u.:: ^r.:n�q m:v n :r:v:n:mu:r.u::..r•.r m:::um:::ms::r. <br /> .......................................:L.:..f.l:......1.......:?..:!!!.i!L.h.H..i:..:...IM...L ..t.F.f.!.....?'..:.:.2...............:...,..9.3:.i?t1N.n..n!tS:.....Pl..!n.itt?......_. ...t.....................:...........:...n..,................t:.:......!ltf....tt..i..n.i.{....,..........t........!...ali.ft........................:i <br /> SWEEPS 0 COMPUTER !! LOC CODE DIST CODE AMOUNT RECEIVED CHECK p/CASiI RECEIVED BY DATE RECEIVED <br /> 1i <br /> III $ <br /> P.i!!ii!'•?!!!t!Tit!nt!nit!!inl0lmnn;.• tntlm?mS917h ..!tn ... 9U,iN!�qr!11.'Imt!11�FIC�MIPMRMMII <br /> 9Smti!li...:.n�IitlAI :�W�g�ptmlNlml9l�lfinl}�riWn iminl.?IIUt!!!n!in!Ilim?tmn.i.nt nIltntlSlliiitt!!Im111i.i111�(i.n�.!#ni.111111.1:) <br /> !?!!lI[!!!Iltilln. :n mt niN+ll Hl In:li.Rtn9!i!:.IinilNIHtin{!i....:!: .:?.i.!!11!!ttl!:11111 !I!.1!..:mA..i?i!n:!i6iiii!fi!IIEti!r(i!n!iIm!Initliit!n I 1191M inn!II:HST!?nin!21HIM I.MI.—.V <br /> rtl 74 t177 inGvtccn 11.1.tT'f1 n ., 111 <br />