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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> .-S FACjLITY SITE NAME ( FACILITY CT NAME <br /> T <br /> E FACILITY ADDRESS I SITE PHONE 9 with AREA CODE <br /> & STATE ZIP CODE � of TANKS <br /> CITY at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS \\ APPLICANT PHONE 9 WITH AREA CODE <br /> A O F--��z� ,/-C� �© 4• C�1 1�7 to— 4 003 <br /> N <br /> T CITY STATE ZIP CODE TYPE of APP <br /> (Closure Instal l� etc.) <br /> TOTAL <br /> 1986 11987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A XXXX I )0= I XXXX I XXXX I XXXX s XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED Cif Applicable) I XXXX XXXX XXXX I XXXX XXXX 5 XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) ( S170/TANK (After January 1, 1991) <br /> E' <br /> R Tanks = � 11987 1988 ( 1989 1 1990 1991 i 1992 11993 11994 11995 11996 1997 <br /> F (multiply 4 by fee for <br /> A each year applicable) XXXX XXXX ` XXXX I XXXX XXXX I I I I S 1:�-I <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX I XXXX I XXXX (XXXX I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 Is 5 <br /> T <br /> Y Tanks x 58.00 1988 through 1990 (S56) 1991 through 1996 (556) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXX)CCXXxxxxxx xxxxxxxxxxxxxxxxxm=xx5 <br /> C PERMANENT CLOSURE (Removal 'or Authorized Closure-in-Ptace) TANK I.D. :(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/YANK) ` �` TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. 0(s) <br /> R <br /> El TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) ' 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. ;*(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. "(s) <br /> E <br /> j-- <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 5 <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum 5 <br /> N TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr 5 <br /> I <br /> S1-- <br /> I I i <br /> CI CONSULTATION FEE = 578-00/hr SAMPLING INSPECTION FEE = 578.00/hr ! S <br /> TOTAL DUE S } 7jGj• i�-,6 <br /> FOR OFFICE USE ONLY <br /> ...__... ._....._ ... <br /> Sim— <br /> M <br /> SWEEPS # COMPUTER LOC CODE DIST CODE ( AMOUNT RECEIVED ( CHECK k/CASH I RECEIVED 3Y I DATE RECEIVED _ <br /> EH 23 032 (REVISED 5-27-97) <br />