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SAN JOAQUIN Cr `Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL HF'-�H DIVSION <br /> UI..,,;ROUND STORAGE TANK PROGRAM - FEE WORKSHEE <br /> T-EFACILITY <br /> tADDRESS <br /> FACILITY CONTACT NAME <br /> C-or f1�7 f'1SITE PHONE # with AREA CODE <br /> STATE ZIP CODE # of TANKS� V-% (�5a at SITE <br /> P APPLICANT/BILLING NAME APPl1CANT CONTACT NAME <br /> L -tk: smdtSo h <br /> I <br /> C MAILING ADDRESS APPLICAN11 PHONE # WITH AREA CODE <br /> F•0. Six X30"1 53o- - W14 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> �j r S 0 e 1, G 5q 45 (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100,00 <br /> A X%XX XXXX xx Xxxx XXXX S xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) Xxxx xxxx XXXX I XXXX %XXX S xxxxxXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E A <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 l <br /> F (multiply # by fee for <br /> A each year applicable) xxxx xxxx xxxX xxxx xxxx 170 j7b 1-70 )-10 5loac)-00 <br /> I TANK ;jr <br /> D XXXX XXXX XXXX %XXX XxxX IC)Ck�K � � D 10 17� I� I'� ) 5 QaL <br /> I STATEFACILITIES ONLY=� j O - 00 /0, QO <br /> T <br /> Y # Tan1988 through 1993 (S56) 1993 through 1997 (556) 1998 <br /> X%K%XXXXXXXXXXXXXX%XXXXX%XX XX%XX%XX%XXXXXI(XX%XXXX% 5 8 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234,00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 mini mm S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 mini mm $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimaNFACILITY) = 8234.00 mini mum S <br /> M TRANSFER FEE = 820.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> f <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL DUES, <br /> FOR OFFICE USE ONLY _ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH I RECEIVED BY GATE RECEIVED <br /> i` <br /> a: S <br /> :;:r::;......==:_ _=_:__-:-.//u��..a ,::::,::'-:::::e::::;:;:;::::::r:::::::::_ c:::=_:m[n_:::::'=___:et_-=::::t[::_:_::::=:a-::r::__=__:--_:___ <br /> EH 23 032 (REVISED 1-12-98) J ?�� <br />