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SAN JOAQUIN CC . PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE DIVSION <br />UNVWGROUND STORAGE TANK PROGRAM - FEE WDRKSHEET v <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAM»E� <br />L <br />0 <br />�L \Aci.i�/�3 <br />17987 <br />T <br />-E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />00`7 <br />TANK I.D. #(s) <br />G r <br />January 7, 1991) = 5100.00 <br />& <br />CITY STATE ZIP CODE a of TANKS Z <br />A <br />a[ SITE <br />PAPPLICANT <br />CONTACT NAMEAPPLICAN /BILLING <br />;NANEE5 <br />X%XX <br />A <br /># TANK(s) X 5234,00 = <br />I <br />MAIG ADORES <br />APPLICANT PHONE WITH AREA CODEC <br />A <br />rO - x C SAO <br />N <br />T <br />CI <br />STAIE ZIP CODE _. <br />TY E o PLICATION <br />xxxx <br />7/•�'✓x�-t.,l /T�� <br />(Closure, nstaLlation, etc.) <br />rnr., <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.O. #(s) <br />L <br />0 <br />1986 <br />17987 <br />1988 <br />1989 <br />1990 <br />TANK I.D. #(s) <br />ANNUAL FACILITY FEE (Prior to <br />January 7, 1991) = 5100.00 <br />5234.00 minimum <br />$ <br />XXXX <br />%%%% <br />XXXX <br />%XXX <br />X%XX <br />S X%X%XXXX <br />A <br /># TANK(s) X 5234,00 = <br />5 <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) <br />= $234.00 minimus <br />DI <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) <br />xxxx <br />I xxxx <br />xxxx <br />xxxx <br />xxxx <br />S XXXXX%XX <br />I <br />V TANK FEE = 550.00/TANK <br />(Prior to January 1,7991) <br />I <br />5170/TANK <br />(After <br />January 1, 1991) <br />E <br />9 Tanks = <br />1988 <br />1989 1990 1991 <br />11992 <br />1993 1994 <br />1995 <br />1996 <br />1997 <br />1998 <br />_ <br />F (multiply # by fee for <br />$ <br />A each year applicable) <br />XXXX <br />%XXX XXXX xXXX <br />%%X% <br />I <br />I <br />C <br />I TANK PENALTY FEES ASSESSED � <br />XXXX <br />XXXX %XXX XXXX <br />XX%X <br />5 <br />L <br />I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 <br />$ <br />T <br />Y # Tanks_ x 58.00 <br />1988 through 1993 <br />($56) <br />1993 <br />through <br />1997 <br />(556) <br />1998 <br />XXxxxxxxxxx%XxxXxxxxxxxxxxx <br />xxX%x%XXXXXXXXxxxxxxxxx <br />S <br />SURCHARGE FOR 1998 <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.O. #(s) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimus/TANK) <br />Al TANK(s) 'lam X 5234.00 <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) <br />5234.00 minimum <br />$ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />_ %24.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 878.00/hour (3 hours minimus/TANK) <br /># TANK(s) X 5234,00 = <br />5 <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) <br />= $234.00 minimus <br />S <br />MI TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br />I r <br />CONSULTATION FEE = 578.00/hr <br />FOR OFFICE USE ONLY <br />ass__PUTER <br />SWEEPS # COMPUTER # <br />SAMPLING INSPECTION FEE = 578.001hr <br />ST CODE IIAAMOUNT RECEIVED CHECK */CASH <br />S <br />EH 23 032 (REVISED 1-12-98) v �� <br />S <br />TOTAL OUE I S <br />DATE <br />