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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> ' ROUND STORAGE TANK PROGRAM - FEE WORKSH <br /> 5 FACILITY SITE NAME FACILITY COM NAME <br /> I 0 s o Q 0 CP0 /Vac ie. Sidle <br /> T <br /> E FACILITY ADDRESS/ SITE PHONE # with AREA CODE <br /> & y3 el-.70 — 51.1 y'C7 <br /> CITY STATE ZIP CODE Q # of TANKS <br /> A <br /> 5 D C C C S a 6 / at SITECPI <br /> P APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N 8 V3 i s c ,L 401 c ( 3?-3 — /4�8 <br /> T CITY STATE ZIP CODE TYPE of APP <br /> GU L'S7� .S G C',G} �r-� (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 S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = _�/ 1986 1987 1 1988 1 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for c� <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX S <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> $ /J j <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A C�2N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum $ � <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 minimun/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimm/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE ='$78.00/hr S <br /> TOTAL DUE S O T6 <br /> FOR OFFICE USE ONLY <br /> —_ ._._............................._.__.........._.....«._.__.._... ___....._._.. ....._...__..__.._..._....._..._._.....__........._.___._..._ ._ _ _....._..............._.....................................................«. <br /> SWEEPS ED# I COMPUTER # I LOC CCOE I DIST CODE AMOUNT RECEIVED CHECK /CASH RECEIVBY I DATE RECEIVED <br /> _ <br /> :2 <br /> 9 <br />