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F. SAN JOAQUIN -TY PUBLIC HEALTH SERVICES - ENVIRONMENTALTH DIVISION <br /> U OUND STORAGE TANK PROGRAM - FEE WORKSHEE <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I CFS i-l�3 <br /> T <br /> E FACILITY ADDRESS t SITE PHONE # with AREA CODE <br /> & <br /> CITY STATE ZIP CODE # of TANKS <br /> A C at SITE 1+ <br /> P <br /> P APPLICANT/BILLING NAMEAPPLICANT CONTACT NAME <br /> � `�e �sv <br /> C MAILING ADDRESS i, APPLICANT PHONE # WITH AREA CODE <br /> N �� ,� DJC. NIV ItVr S \O K��S -2-333 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> Lkar C,Lt (Closure, Installation, etc.) <br /> �.e•� 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 $ 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 = 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 x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> $ <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 $ <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 $ <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> ..:.......:..._......._:.....:._............._................ _................:......_:......::..::.::..:................_.._:.................................:.....:...:..... w...._..._::.._:_..:.:..........................:.....................:....................:........::::.......:........................................................... <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br />