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SAN JOAQUIN Cr'"+TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL '-TH DIVSION I tGROUND STORAGE TANK PROGRAM - FEE WORKSHL_ S FACILITY SITE NAME-rQft�K FACILITY CONTACT NAME T R - E ni S rrE - 'E FACILITY ADDRESS SITE PHONE # with AREA CODE r F41215 67a c32- 7 U TEMPORARY CLOSURE (Plan Review b Inspections) TANK I.D. #(s) R XXXX Xx%X CITY STATE ZIP CODE # of TANKS A C S �- q5 376 at SITE P T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXXXXX% P APPLICANT/BILLING NAME APPLICANT CONTACT )NAME LL I N V TANK FEE = S50.00/TANK (Prior to January 1,1991) E 5170/TANK (After January 1, 1991) # Tanks = C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A2o4p N ?E-Ai;ot>Y ROAD 1993 T CITY STATE ZIP CODE TYPE of APPLICATION "ST nos") -E; Vti1GAMLLE (}E C1510817(Clo sure, Installation, etc.) 3 qN TOTAL C 1986 1987 11988 1989 1990 0 S ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 # TANK(s) 3 x 5234.00 = S 7(]2 U TEMPORARY CLOSURE (Plan Review b Inspections) TANK I.D. #(s) R XXXX Xx%X X%XX xxxx XXXX S X%X%X%%X A C S �- T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXXXXX% Xx%% %XXX xxxx I s xxxxx%xx i V TANK FEE = S50.00/TANK (Prior to January 1,1991) E 5170/TANK (After January 1, 1991) # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 F (multiply # by fee for xxxx XXXX xxxx I xxxx xxxx $ A each year applicable) C I TANK PENALTY FEES ASSESSED XXXx xxxx xxxx xxxx %%XX I S L I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 T S $ Y # Tanks= x 58.00 1988 through 1993 ($56) 1993 through 1997 (S56) 1998 SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx S C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) L I 0 S CLOSURE FEE = 578.00/hour (3 hours minimiVTANK) # TANK(s) 3 x 5234.00 = S 7(]2 U TEMPORARY CLOSURE (Plan Review b Inspections) TANK I.D. #(s) R TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimumS E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum s -69- P INSTALLATION PLAN CHECK (Plan Review d Construction Inspections) TANK I.D. #(s) L I A TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = N PLAN CHECK FEE = S78.00/hour (8 hours minirmm/FACILITY) = S624.00 minimm S —4GL—P R REPAIR FEE (Workplan Review d Construction Inspections) TANK I.D. #(s) E I P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = 5 A TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimumS RI -� PIPING REPAIR FEE - S78.00/hour (3 hours minimus/FACILITY) = $234.00 minimm S �- ITRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S 9 Sl I C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 _ TOTAL DUE s FO .O R R.t USE ONLY ;q :+rn:n r .n:mnmm SWEEPS # 1 COMPUTER EH 23 032 (REVISED 1-12-98) CODE I AMOUNT RECEIVED I CHECK #/CASH I RECEIVED .... 8.Y I u DATE s