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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> UdM&VGRaJND STORAGE TANK PROGRAM - FEE YORKSH <br /> S FACILITY SITE NAME FACILITY ART NAME <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & <br /> CITY STATE ZIP CODE I # of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/PIA.LIN6 AME I APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE I TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX XXXX I XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T .FACILITY PENALTY FEES ASSESSED (If Applicable) , XXXX XXXX I XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 11990 1991 11992 1993 1994 11995 11996 <br /> F (muL tiply # y fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX I 0 S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX I I 5 <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter mount and year) <br /> 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_�$_ X 5234.00 = 5 _� <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A / <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 6 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minim/TANK) # TANK(s) X 5234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = S78.00/hr ! 5 <br /> TOTAL DUE S 22j� <br /> FOR OFFICE USE ONLY <br /> SWEEPS # l COMPUTER # ( LOC CODE ( DIST CODE ( AMOUNT RECEIVED I CHECK */CASH I RECEIVED 3Y ` DATE RECEIVED <br /> s:«._..«. . <br /> ...............»......... .__........_. ..._...^._....«.._.^._:::..nr.:r.^.............. •• _.«.^^._ ._... .�;:•x;ynas.~W„::.....___=•e^—• o......::R;^^;.^:.: <br /> �. <br />