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0 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />FACILI Y SITE NAME <br />FACILITY CONTACT NAME <br />FACILITY ADDRESSSITE <br />PHONE # with REA COOS <br />O h. 6 a.�n G <br />—7 <br />969-;Z37S <br />CITY <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br />ZIP CODE <br /># of TANKS <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />��SppTATE <br />tXC_ <br />15-33 & <br />at SITE <br />APPLICANT/ ILLING NAME <br />APPL CANT CONTAC NAME <br />MAILING AD SS <br />APPLICANT PHONE # (ATH AREA CODE <br />70 ® /0 <br />2®q - X23 - /l-{/ <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />1, 1991) <br />1997 1998 <br />0, <br />/- <br />S3 3 <br />(Closure, Installation, etc.) <br />TOTAL <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />TANK I.D. #(s) <br />1986 <br />XXXX <br />1987 1 <br />XXXX <br />1988 ( <br />1989 <br />1990 <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br />XXXX I XXXX XXXX <br />$ XXXXXXxx <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />I XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ xXXXXXXX <br />TANK FEE = $50.00/TANK <br />I <br />9 Tanks = <br />(multiply # by fee for <br />each year applicable) <br />(Prior to January 1,1991) <br />1988 1989 1990 1991 <br />XXXX XXXX XXXX XXXX <br />1992 <br />XXXX <br />3170/TANK <br />1993 ( 1994 <br />(After <br />1995 <br />I <br />January <br />11996 <br />1, 1991) <br />1997 1998 <br />$ <br />TANK PENALTY FEES ASSESSED XXXX I XXXX Fxxxx XXXX <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 <br />XXXX <br />I <br />I <br />$ <br />$ <br /># Tanks x $8.00 <br />SURCHARGE FOR 1998 <br />1988 through 1993 <br />($56) <br />1993 <br />through 1997 ($56)1 <br />1998 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) <br />J CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) # TANK(s)_a_ X 5234.00 = S o <br />. DQ' <br />J TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />2 <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br />?I INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br />NI PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum 3 3 N <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />s <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br />$ <br />N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I S <br />I <br />S <br />C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = 378.00/hr $ <br />TOTAL DUE $ <br />OR OFFICE USE ONLY <br />SWEEPS # ( COMPUTER # 1 LOC CODE <br />M 77 n17 (RFVTSFn 1-12-9R) <br />DIST CODE AMOUNT RECEIVED CHECK #/CASH <br />$ <br />RECEIVED BY I DATE RECEIVED . <br />