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SAN JOAQUIN COU' PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEA' DIVSION <br /> ' UND`,<OUND STgRAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME A TY CONT C NAME <br /> I C <br /> T <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & - S 1J a �o ti� vac <br /> L1TY1 b C ���� C�STATEI21P 5 63 # of TANKS <br /> CODE <br /> A at SITE <br /> P APPLICANT/BILLING NAME 1APPLICANT CONTACT NAME <br /> 6Tb G gU *, s6 f kr SKtLF�rS <br /> C MAI LI ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A ` <br /> NC <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> osure Installation, etc.) ►U fj <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A xxxx xxxx xxxx XXXX X%X% S xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXX% xxxx I XXXX $ Xx%Kxx%X <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx xxxx xxxx xxxx xxxx 7D 6) 17Y / 60 / TTO <br /> I TANK PENALTY FEES ASSESSED xxxx XXX% XXxX XXXX XXXX Q• /76 176'11-7d (, a T /U S , <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T <br /> T # Tanks x $8.00 1988 through 1993 (S56) E <br /> 1993 through 1997 ($56) 1998 <br /> SURCHARGE FOR 1998 XX%%xXxxxxxxxxxxxxxxxxxxxxx xxxXxXxxxxxxxXxXxXxxxxx $ <br /> o!� <br /> C PERMANENT CLOSURE (Removat 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) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 mini mm $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK [.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 mini mm $ <br /> N TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> :::::: ::::::::: ::::::::::::_:::::.:.........__......:............._....:.::..:..:::::::::::: ::::::::::::::::::::::::_::::_ ���,.............._........._..__......_........_...............:,.._..._..�....:: <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> S <br /> ......................._............................._...._..._.....:......__..: .......................................................__..............._.._.....__......._........_...._.._. ;__._._..............__.:_........._._....[r:=aq _ <br /> :.::::-:,::::__.:::_:-:::::::::::::::::::::::::_::::: ..._.............................................._..............................................._................._,.___.__......................_.._-...:.....r_....._.._ ..__. <br /> e <br /> EH 23 032 (REVISED 1-12-98) <br />