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• SAN JOAQUIN COUNABLIC HEALTH SERVICES - ENVIRONMENTAL HEALTMVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />'FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />A <br />l N <br />I <br />T <br />S <br />1986 <br />1487 11488 1989 <br />1990 <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />$ <br />XXXX <br />XXXX I XXXX I XXXX <br />XXXX <br />$ XXXXXXXX <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />at SITE <br />P <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />S <br />I XXXX <br />XXXX XXXX I XXXX <br />XXXX <br />$ XXXXXXXX <br />I <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />S <br />:_ <br />_....._......_._.__.. <br />I <br />SWEEPS # I COMPUTER # I LOC CODE ( DIST CODE + AMOUNT RECEIVED I <br />CHECK #/CASH I RECEIVED BY ( <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />1991) <br />N <br />T <br />CITY <br />STATE) ZIP CODE <br />TYPE of APPLICATION <br />1994 , 1995 1996 ( 1997 <br />I <br />(Closure, Installation, etc.) <br />Cl <br />PERMANENT CLOSURE (Removal or Authorized Closure - in -Place) <br />I TANK I.D. #(s) <br />A <br />l N <br />TOTAL <br />= S624.00 minimum <br />S <br />1986 <br />1487 11488 1989 <br />1990 <br />S <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />$ <br />XXXX <br />XXXX I XXXX I XXXX <br />XXXX <br />$ XXXXXXXX <br />A <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />C <br />S <br />M <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />S <br />I XXXX <br />XXXX XXXX I XXXX <br />XXXX <br />$ XXXXXXXX <br />I <br />= S78.00/hr <br />S <br />FOR OFFICE USE ONLY <br />TOTAL DUE <br />S <br />:_ <br />_....._......_._.__.. <br />_- .. r _ _ _ _ <br />µ- <br />SWEEPS # I COMPUTER # I LOC CODE ( DIST CODE + AMOUNT RECEIVED I <br />CHECK #/CASH I RECEIVED BY ( <br />V <br />TANK FEE _ $50.00/TANK (Prior to January 1,1991) I <br />5170/TANK <br />(After January 1, <br />1991) <br />E <br /># Tanks = <br />1987 1988 ` 1984 <br />1 1990 1991 <br />( 1992 1993 , <br />1994 , 1995 1996 ( 1997 <br />F <br />(multiply # by fee for <br />XXXX XXXX XXXX <br />XXXX XXXX <br />I <br />I ( <br />! <br />S <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX I XXXX I XXXX <br />XXXX (XXXX I <br />i I <br />( <br />$ <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 <br />0$ <br />T <br />Y <br /># Tanks x 58.00 <br />1988 through 1990 (S56) <br />1991 through <br />1996 (S56) <br />1997 <br />I <br />' <br />SURCHARGE FOR 1997 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />Cl <br />PERMANENT CLOSURE (Removal or Authorized Closure - in -Place) <br />I TANK I.D. #(s) <br />A <br />l N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) <br />= S624.00 minimum <br />S <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = S <br />S <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />$ <br />Y <br />R <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum <br />$ 2 <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />I 5234.00 minimum S <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />A <br />l N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) <br />= S624.00 minimum <br />S <br />R <br />t E <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />P1 <br />A <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />Y <br />R <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum <br />$ 2 <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum <br />S <br />M <br />TRANSFER FEE = S20.00 I I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I <br />$ <br />S <br />Ci <br />CONSULTATION FEE = S78.00/hr I ( SAMPLING INSPECTION FEE <br />= S78.00/hr <br />S <br />FOR OFFICE USE ONLY <br />TOTAL DUE <br />S <br />:_ <br />_....._......_._.__.. <br />_- .. r _ _ _ _ <br />µ- <br />SWEEPS # I COMPUTER # I LOC CODE ( DIST CODE + AMOUNT RECEIVED I <br />CHECK #/CASH I RECEIVED BY ( <br />DATE RECEIVED <br />iS <br />EH 23 032 (REVISEED 5-27-97) <br />