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SAN JOAQUIN C- >Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL HF -H DIVSION <br /> L64,0GROUND STORAGE TANK PROGRAM - FEE WORKSHEEr,d <br /> SL FACILITY S E NAgI� Is I FACILI CONTA ME� ' <br /> I (� JiSLO <br /> T <br /> E FACILITY ADDRESS / SITE PHON # with AREA CODE <br /> & SU <br /> CITY c S,TAjE ZI CODEAI # a TANKS <br /> A S "N �-7N3 at SITE <br /> P <br /> P APPLICANT/BILLING N n APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 Lm <br /> 1988 1989 7990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX xxxx XXXX XXxx XXXX S XXXXX%XX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX X%XX 5 XX%%X%XX <br /> i <br /> V TANK FEE = 850.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks _2-� 1988 1989 1 1990 1 1991 1992 1 1991 79qg 1g9/ 1 <br /> F (multiply X byby fee for <br /> A each year applicable) XXX% <br /> C XXX% XXXX x%%X XXXX / 701-70 1 1170X70 /70 00 5 O 7D <br /> ITANK PENALTY FEES ASSESSED xxxx XXXX XXXX XXXX xX%X 10 it 7D /70 /-?d 170 5 (� <br /> L , <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 5 <br /> T <br /> T # Tanks -x $8.00 1988 through 1993 (556) 1993 through 1997 (S56) <br /> SURCHARGE FOR 1998 XXXXXxxxxxxxxxxxxxxxxxxxxxx XXXXXXX%XxxXxxXxxxxxxxX tl S / <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L rl �/ <br /> 01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)��X $234.00 = 5 6 D fT <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) QL Z/ <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I $234.00 minimum 5 <br /> P! INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minima S <br /> R! REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) Al TANK(s) X 5234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minima/FACILITY) = S234.00 minimum S <br /> N TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr 5 <br /> i <br /> Si <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr 5 <br /> TO AL DUE S ZS <br /> FOR OFFICE USE ONLY b 51 . <br /> . _ :::- .___:::. a__=:[--_xI_::t_ <br /> SWEEPS # COMPUTER # LOC CODE GIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> z <br /> 5 <br /> EH 23 032 (REVISED 1-12-98) <br />