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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY CONiyACT NAME <br />1 <br />C — <br />1988 <br />T <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) . MOO -00 <br />0 z <br />20g - - %) Sr G <br />XXXX <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS C37To W& V -U M61C RIB <br />SAMPLING INSPECTION FEE _ %78.'O0/hr <br />�® ' <br />C-� <br />ZSZ� 0 <br />at SITE z 6 i Kul <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />xxxx <br />XXXX <br />XXXX <br />I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />N <br />1Z�1 ALLPkN` a <br />)U 0 <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APP <br />n`' <br />1992 <br />1993 <br />L-•1" <br />CSG( <br />(Closure, Instaliati etc.) <br />1997 <br />� <br />,_ <br />(multiply # by fee for <br />TOTAL <br />PERMANENT CLOSURE (Removal or'Authorited Closure -in -Place) <br />TANK I.D. #(s) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />TEMPORARY CLOSURE (Plan Review b Inspections) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) . MOO -00 <br />%XXX <br />XXXX <br />XXXX <br />XXXX <br />XxX% i XXXXXXxx ` <br />A <br />SAMPLING INSPECTION FEE _ %78.'O0/hr <br />5 <br />TOTAL DUE <br />t <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />xxxx <br />XXXX <br />XXXX <br />XXX%' S % <br />t <br />V <br />TANK FEE = 550.00/TANK (Prior td January 1,1991) <br />1170/TANK (After January 1, 1991) <br />E <br />0 Tanks e <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />1997 <br />F <br />,_ <br />(multiply # by fee for <br />5 <br />A <br />each year applicable) <br />%XXX <br />X%KK <br />xxxx <br />xxxx <br />XXXX <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />5 <br />L <br />I <br />` <br />STATE SURCHARGE FOR NEN FACILITIES ONLY = 518.50 C x.� 5-t, Aa <br />T <br />Y <br /># TankS_ x 58.00 <br />1988 through 1990 (556) <br />1991 through 1996 MIS) <br />199 <br />xxxxxxxxxxxxxxxxxxxxxxxxxxx <br />XxxxxXxXxxxxxxxxxxxxxxx <br />5 <br />SURCHARGE FOR 1997 <br />C <br />PERMANENT CLOSURE (Removal or'Authorited Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = 978.00/hour (3 hours minimus/TANK) <br /># TANK(s) X $234.00 = <br />5 <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review b Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 378.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />5 <br />P <br />INSTALLATION PLAN CHECK (Plan Review A Construction Inspections) <br />TANK I.D. #(s) D <br />L <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />A <br />N <br />r, <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum 1A S H, <br />5 �t <br />R <br />REPAIR FEE (Workplan Review 8 Construction Inspections) <br />TANK I.D. #(s) 3 <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />5 <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />5 <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) ■ $234.00 minimum <br />5 <br />M <br />TRANSFER FEE = $20.00 <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />5 <br />1 <br />S- <br />C <br />CONSULTATION FEE a 578.00/hr <br />SAMPLING INSPECTION FEE _ %78.'O0/hr <br />5 <br />TOTAL DUE <br />FOR OFFICE USE ONLY p <br />. om c:o o r r c o n r! { rm r r r n r t roc o? c c s}up}!pmnnnu r}o an}!n•£!!?!!!!£!!!!!!!£i?!??i!!fEl)1!!!go!}}}},yg±}i!n?}m!!!!!?I!I!£!B!}}}n!}nn}!t?£?!!t!!!B!!!£!!}3t!i!!3£!?!!!!m!•,}nr„7fi• <br />m0111111r,m u r aunn .raoac c nn r r m u c nn .£l...!!!Li -MISM: <br />£..i..!?!1.i.......Il.........fiif!l....i.:.1l.Il..li....l.....l.� . � I ..... . ... .... .... ... .... .... :.:.. ... ......... • <br />........ ......... .. ... .. .. .. ... ...... ......... .. ...:.. :.:.a. r .r�c : o r c: •••: •r c .o , .r.rr c, h qr„ c,r.:::±•:e{!{i?a{{?.{z:±re !:£:£:!±a:ilREre!cF.:r.:ar!?£AiB{?£i?i!i•:i±r?::a::nc?i?!iiiel?±i{i:.:nraiiciii!h°iui!:£riiclil::l:??rdF?i?:ir:EL•i!im:�:vr.:[uU: <br />ii£uel:nreB:3?*rm.:icA£F:::{:aa£rhei:?rr.::I?iraW:cin?:!a::e: a:•..Af...3.E....cN�.riiiEi..:t.liiiclilliffll. ...e <br />SWEEPS # I COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY I DATE RECEIVED <br />5 <br />i <br />