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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMMAL HEALTH DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE woRY,SHEET <br />M RANSFER FEE = S20.00 f I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I ; ( S # <br />SI <br />C. CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr I S <br />TOTAL DUE S %J71 <br />FOR OFFICE USE ONLY <br />_ SWEEPS COMPUTER 9 + LOC CODE DIST CODE ' AMOUNT RECEIVED ( CHECK <br />RECEIVED 3Y <br />DATE RECEIVED <br />SI FACILITY SITE . ME <br />FACILITY CONTACT N <br />T I <br />�' <br />1989 11990 <br />I <br />j <br />EI FACILITY ADDRESS <br />i SITE PHONE 9 wi` AREA COD_ <br />Ai <br />XXXX + XXXX i XXXX i <br />XXXX XXXX S <br />./ <br />C` <br />T <br />^I <br />1 <br />XXXX j XXXX j XXXX j <br />TE� <br />Z CODE i of TANKS <br />I: <br />Al T <br />1 <br />at SITE E <br />V; <br />P. <br />5170/TANK (After January <br />1, 1991) <br />�" <br />D I APPL /�11NGE <br />/ <br />j P LICANT CQNTACT = <br />Fi <br />(MU I,iDIY R by fee for <br />A <br />C; MAIL NG ADDRESS <br />I <br />i S <br />I APPLICANT PHONEuIT AREA CODE t <br />C. <br />Al <br />�y <br />I <br />N' <br />L` <br />TI <br />i V4ATc+ ; <br />ZCmc TYPE of APPLICATION <br />Ij <br />',7/�/► s%Y/ <br />i � <br />"��"� "�" (Closure, Ins:ai Cation, etc.) <br />M RANSFER FEE = S20.00 f I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I ; ( S # <br />SI <br />C. CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr I S <br />TOTAL DUE S %J71 <br />FOR OFFICE USE ONLY <br />_ SWEEPS COMPUTER 9 + LOC CODE DIST CODE ' AMOUNT RECEIVED ( CHECK <br />RECEIVED 3Y <br />DATE RECEIVED <br />TOTAL <br />1986 1987 { 1988 j <br />1989 11990 <br />j <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />Ai <br />XXXX + XXXX i XXXX i <br />XXXX XXXX S <br />XXXXXXXX <br />C` <br />T <br />FACILITY PENALTY FEES ASSESSED (if Applicable) <br />1 <br />XXXX j XXXX j XXXX j <br />XXXX XXXX 6 S <br />XXXXXXXX <br />I: <br />1 <br />V; <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) i <br />5170/TANK (After January <br />1, 1991) <br />�" <br />= antis = 1987 j 1988 11989 i 1990 1991 i <br />1992 1993 1994 1995 <br />1996 j 1997 <br />Fi <br />(MU I,iDIY R by fee for <br />A <br />each year apaiicabie) f XXXX i XXXX i XXXX I XXXX IXXXX f <br />I <br />i S <br />E <br />C. <br />I <br />TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX Jun <br />L` <br />Ij <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 <br />�S <br />T" <br />Y <br />Tanks x 58.00 1988 through 1990 (S56) <br />1991 through 1996 (S56) 1997 <br />Y <br />SURCHARGE FOR 1997 I X)D=XXX)O=XXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />Ci <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. :(s) <br />L; <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) j <br />TANK(s) X S234.00 <br />= S <br />sj <br />Uf <br />TEMPORARY CLOSURE (Pian Review & Inspections) I <br />TANK I.D. A(s) <br />R• <br />Ej <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) l <br />5734.00 minimum <br />S <br />P <br />114STALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. :(s) <br />L; <br />Al <br />; <br />Nj <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) <br />= S624.00 minimum <br />S <br />w <br />M RANSFER FEE = S20.00 f I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I ; ( S # <br />SI <br />C. CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr I S <br />TOTAL DUE S %J71 <br />FOR OFFICE USE ONLY <br />_ SWEEPS COMPUTER 9 + LOC CODE DIST CODE ' AMOUNT RECEIVED ( CHECK <br />RECEIVED 3Y <br />DATE RECEIVED <br />