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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONNENTAL HEALTH DIVSION i
<br /> UNDERGROUND STORAGE TANK PROGRAN - FEE WORKSHEET
<br /> S FACILITY SITE NAME FACILITY CON CT NAME
<br /> I r j
<br /> T t
<br /> E FACILITY AD ESS SITE PHONE # with AREA CODE
<br /> a
<br /> CITY STATE ZIP CODE # of TANKS
<br /> A . et SITE
<br /> P
<br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME
<br /> L
<br /> 1
<br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE
<br /> A
<br /> T CITY STATE ZIP CODE TYPE of APPLICATION
<br /> (Closure, Installation, etc.)
<br /> 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 % xxxXxXxX
<br /> C - 4
<br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) xxxx xxxx xxxx xxxx XXXX' % Xxxxxxxx
<br /> i
<br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 1170/TANK (After January 1, 1991) d
<br /> E 046 j
<br /> # Tanks = 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1 6 0. !)� >47
<br /> ' F (multiply 0 by fee for s
<br /> A each year applicable) XXXx Xxxx xxxx xxxx xxxx $ "%
<br /> C f
<br /> I TANK PENALTY FEES ASSESSED xxxx XXXx xxxx xxxx xxxx a
<br /> L
<br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50
<br /> T
<br /> Y # Tanks H x $8.00 1988 through 1990 . ($56) 1991 through 1996 (f56) 1997 !�
<br /> 1
<br /> SURCHARGE FOR 1997 xxxxXxXxxxxxxxxxxXxxxxxxxxx xxxxxxxxxxxXxxxXxxxxxxx f Z,oo
<br /> I ,
<br /> (
<br /> C PERMANENT CLOSURE (Removel or Authorized Closure-in-Place) TANK I.D. #(s) '
<br /> L
<br /> 0 CLOSURE FEE = !78.00/hour (3 hours minimum/TANK) 0 TANK(s) X $234.00 f
<br /> S
<br /> U TEMPORARY CLOSURE (Plan Review b Inspections) TANK I.D. N(s)
<br /> i R
<br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum f
<br /> P INSTALLATION PLAN CHECK (Plan Review a Construction Inspections) TANK I.D. #(s) 44
<br /> L
<br /> A -
<br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) %624.00 minimum f Z/�
<br /> R REPAIR FEE (Workplan Review a Construction Inspections) TANK I.D. #(s)
<br /> E
<br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) 0 TANK(s) X %234.00 f
<br /> A
<br /> I TANK RETROFIT REPAIR FEE = E78.00/hour (3 hours min./FACILITY) _ %234.00 minimum f
<br /> R[-
<br /> 'i PIPING REPAIR FEE _ $78.00/hour 0 hours minimum/FACILITY) $234.00 minimum f
<br /> •
<br /> i N TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $
<br /> I
<br /> S
<br /> 1 C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.'00/hr f'
<br /> i
<br /> TOTAL DUE %
<br /> FOR OFFICE USE ONLY
<br /> , n,u•,m ,t
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