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SAN JOAQUIN COUNTY•PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH UiVSION <br /> `UWFJWD STORAGE TANK PROGRAM - FEE WORKSHEET AML <br /> Sj' FACILITY SITE NA� I FACILITY CCNTA .IME <br /> I <br /> T <br /> 'EFACILITY ADDRESS i SITE PHONE with AREA CODE <br /> CITY �G STATEI ZIP CODE I of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/8 LING N E APPLICA T CONTACT NAME <br /> C' MAILING ADDRESSAPPLI T PHONE T WITH AREA CODE <br /> Ti CITY S4gE Z1 �- .d TYPE of APPLICATION <br /> '(Closure, Instaltatton, etc.) <br /> TOTAL <br /> 1986 i 1987 11988 ! 1989 � 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX ' XXXX I XXXX j XXXX XXXX S XXXXXXXX <br /> C' t <br /> T� FACILITY PENALTY FEES ASSESSED (If Applicaole) XXXX ` XXXX I XXXX XXXX I XXXX 13 xXXXXXXX <br /> I <br /> V1 TANK FE° = S50.00/TANK (Prior to January 1,1991) ` 5170/TANK (After January 1, 1991) <br /> E <br /> T Tanks = 1988 11989 ( 1990 1991 11992 i 1993 Ii 1994 1995 1996 { 1997 <br /> tiPLy # by fee <br /> r <br /> A` ?achyear applicable) i XXXX I XXXX I XXXX xXXX iXXXX <br /> C, <br /> i <br /> 11 TANK PENALTY FEES ASSESSED ' XXXX i XXXX I XXXX XXXX jXXXX <br /> L, <br /> II STATE SURCHARGE FOR NEW FACILITIES ONLY=S18.50 S <br /> T <br /> YI T Tanks x $8.00 ` 1988 througn 1993 (S56) , 1993 through 1997 (S56) 3 �� <br /> SURCHARGE FOR 1998 ( XXXXXXXXXXXXXXXXXXXXXXXXXXX , XXXXXXXXXXXXXXXXXXXXXXX l S <br /> C; PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) j TANK I.O. +(s) <br /> L <br /> Oj CLOSURE FE_ = S78.00/hour (3 hours minimum/TANK) ; 4 TANK(s) X 5234.00 = I S <br /> S' <br /> UI TEMPORARY CLOSURE (Plan Review & Inspections) j TANK E.O. �-(s) <br /> R <br /> E: TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) j 5234.00 minimum S <br /> PI :NSTAL_ATICN PLAN CHECK (Plan Review & Construction Inspections)i TANK I.D. +(s) <br /> LI <br /> t <br /> Al <br /> NJ PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R} .REPAIR FE_ (Workplan Review & Construction Inspections) TANK I.D. '+(s) <br /> E n = <br /> Pj TANK LINING REPAIR FE. = 578.00/hour (3 hours minimum/TANK) 4 TANK(s) X 3234.00 S <br /> A <br /> II TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5734.00 minimum S <br /> R, <br /> I PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 :minimum S <br /> Mi TRANSFER FEE = $20.00 ` I UNAUTHORIZED .RELEASE EVALUATION = S78.O0/hr I I S <br /> I� <br /> S! I I <br /> Ci CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = 578.00/hr ` j S <br /> TOTAL DUE S a <br /> FOR OFFICE USE ONLY <br /> ::... <br /> ........................................_................. �.._. __._.�_..._......._. <br /> ...................._.........�... •c....;;r.:.ra:s_msm::,_e _ ._ __._.........p........ ........_._s».........,:_r.:r-x.::sos:rsa::: <br /> ~�—SWEEPS � � CCMPUTER 4 � LOC CCDE � DIST CODE I AMOUNT REr. IVED CHECK $/CASH I RECEIVED 3Y I DATE RECEIVED <br /> ..__........................._. <br /> _H 23 032 (REVISED 1-12-98) <br />