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SAN JOAQUIN Lr(Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL LSH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SFACILITY SITE NAME FACILITY CONTACT NAME <br /> I Ad - ArT b4r er <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 3 13 3 <br /> N. Ad Y1r? Road =oq - 31 - o86b <br /> & STATE ZIP CODE # of TANKS <br /> A CITY <br /> 510CK10 [/} gSZls at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L A4VFMr+ G-0F"V; roll hi'MY4 Kev1' l4 MrK;{J*Vj <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> A 4005 IV, V111jr6ki W4 1oq y67 - 1006" <br /> T CITY <br /> N STATE ZIP CODE_ PPL ICAT I ON <br /> STa r!{)otn eh, g51.o y (Closure, Installation, etc.) <br /> I TOTAL <br /> 1986 1987 1988 1989 7990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A xxxx xxxx xxxx xxxx xxxx s XXxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %%%X X%X% X%%% xxxx xxxx s xxxxxxxx <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = _ 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx xxxx xxxx xxxx xxxx 5 <br /> CI S <br /> I TANK PENALTY FEES ASSESSED xxxx XX%x xxxx XXX% XXx% <br /> L <br /> I STATE SURCHARGE _ <br /> T <br /> Y # Tanks_ x $8.00 1988 through 1990 (S56) 1991 through 1996 (S56) 1997 <br /> SURCHARGE FOR 1997 XX%%XXxxxX%%XX%XX%XXX%%K%%% XXXXXXXX%X%X%%%XXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) X 5234.00 = S 4 61-00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> RS <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> AS <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minim nVFACILITY) = $624.00 minimum <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> AS <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> RS <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I <br /> 5S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE S Li G s•o r <br /> FOR OFFICE USE ONLY <br /> __..._.....-.—�............. ___................_....r........._._................_......._.. _.__.._..___. <br /> __. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECE) <br /> S _ <br /> v � <br /> EH 23 032 (REVISED 5-27.97) <br />