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SAN JOAQUIN CC " PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEA--` DIVSION <br /> Uk,.0OUNO STORAGE TANK PROGRAM - FEE WORKSHEETS.01 <br /> 5 FACILITY S ENA , FACIL1 CONTAgZ-MAME,� ' <br /> I G2i <br /> T SITE PHON # with AREA CODE <br /> 'E FACILITY ADDRESS / <br /> s �J'Sc�v <br /> 3 S A E ZI CODE # o TANKS <br /> CITY �r-� D1� at SITE <br /> AS J W <br /> P p APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING <br /> L - <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 I XXXX I XXXX XXXX I xxxx xxxx 5 X%XXXXxX <br /> A <br /> D xxxx xxxx xxxx xxxx xxxx 5 x xxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> EI # Tanks -� 1988 1989 1990 1991 1992 I 1 199,�j 1 195 199, 1al l.✓ {�q <br /> F (multiply # by fee for /, <br /> A each year applicable) xxxx xxxx xxxx XXXX xxxx 1/ 701 /70 170 /701 /70 /70 5 U ZD <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx XXXX XXX% XXXX xxxx 7� � 70 / 70 /7Q /7 0 O 5 <br /> LFSTATE <br /> S <br /> RCHARGE FOR NEW FACILITIES ONLY=518.50 <br /> �x 58.00 1988 through 1993 (556) 1993 through 1997 (S56)GE FOR 1998 XXxxxxxxxxXXXXXxxx%XXxxxxxx XXX%xxxxxxxxxxxxxxxxxxx 'V S <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L # TANK(s) X 5234.00 = 5 <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) ,SyY/ <br /> S TANK I.O. #(s) - SYW Oz Z/ U <br /> U) TEMPORARY CLOSURE (Plan Review 8 Inspections) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) i 5234.00 minimum 5 <br /> P1 INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspectians)I TANK I.D. #(s) <br /> LI <br /> A 5 <br /> NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minima" <br /> RI REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E # TANK(s) % 5234.00 = 5 <br /> P TANK LINING REPAIR FEE = S78.o0/hour (3 hours minimum/TANK) <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 minimum/FACILITY) = 5234.00 mini mum 5 <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S = 878.00/hr S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br /> FOR OFFICE USE ONLY r 'y� •-� T1 A_ TO FAL DUE $.:::::...:::+;..:::;- <br /> mma_ .....: ....:::-i' €'_.. R IVED BY DATE RECEIVED _. <br /> s'1 <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH E E <br /> _._...... r--.._ I$ ..___—_—_ _ <br /> EH 23 032 (REVISED 1-12-98) <br />