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SAN JOAQUIN CCl' _v PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE DIVSIOH <br />UN,_.,ROUND STORAGE TANK PROGRAM - FEE WORKSHEET -.04 - <br />S <br />I <br />T <br />F4CILITY 5178 NAME <br />(ec7 %av'Prr,D <br />1987 <br />1 <br />FACILITY CONTACT NAME <br />1989 <br />1990 <br />TANK I.O. N(5) <br />EI <br />ANNUAL FACILi?Y FEE (Prior <br />to January 1, 1991) = S100.00 <br />'E <br />FACILITY ADDRESS <br />�S-*7r— <br />PI <br />L <br />INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. H(s) <br />SITE PHONE H with AREA CODE <br />I S XXXxxxxx <br />A <br />xxxx xxxx I xxxx XXXX xxxx <br />C <br />RI <br />EL <br />A <br />P <br />CITY <br />PI <br />A <br />I S-AEI <br />n_ <br />ZIP CODE <br />I atoSITENKS <br />P <br />APPLICANT/BILLING NAME <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />I XXXX <br />APPLICANT CONTACT NAME <br />` <br />I <br />I XXX% <br />5 zxxXXXXX <br />I <br />TRANSFER FEE= 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr i <br />S <br />=' <br />CONSULTATION FEE = 578.00/hr I I SAMPLING INSPECTION FEE <br />= 578.001hr <br />C <br />MAILING ADDRESSPPL[ <br />TANK FEE.= 550.00/TANK <br />(Prior cc January 1,1991) <br />5170/TANK <br />NT PHONE WITH AREA CODE <br />A <br />3! 8L7 L' dQJ <br />C', Vot-) AAS <br />5yi7� Zza <br />9 LS� 0(4 6 - 804 <br />7 <br />CITY Q, <br />dJ-M-J �i}tyy>� <br />ATE <br />// <br />IP CODE TYPE of APPI!CATION -05c.t/lo� <br />Ota <br />Kj 3 (Closure, -Installation, <br />etc.) <br />T0TAL <br />CI <br />LL <br />PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) <br />I TANK I.O. @(s) <br />1986 <br />1987 <br />1 <br />11988 <br />1 <br />1989 <br />1990 <br />TANK I.O. N(5) <br />EI <br />ANNUAL FACILi?Y FEE (Prior <br />to January 1, 1991) = S100.00 <br />PI <br />L <br />INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. H(s) <br />A <br />NI <br />I S XXXxxxxx <br />A <br />xxxx xxxx I xxxx XXXX xxxx <br />C <br />RI <br />EL <br />REPAIR FEE (Workplan Review 8 Construction Inspections) <br />I TANK I.D. :(s) <br />PI <br />A <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />I H TANK(s) X 5234.00 = <br />I 'TANK <br />R <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />I XXXX <br />I XX%% I <br />XXXX <br />I XXX% <br />5 zxxXXXXX <br />I <br />TRANSFER FEE= 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr i <br />S <br />=' <br />CONSULTATION FEE = 578.00/hr I I SAMPLING INSPECTION FEE <br />= 578.001hr <br />V <br />TANK FEE.= 550.00/TANK <br />(Prior cc January 1,1991) <br />5170/TANK <br />(After <br />January <br />1, <br />1991) <br />E <br />11988 <br />1989 11990 11991 11992 <br />11993 11994 <br />11995 <br />11996 ( <br />1997 <br />11998 <br />F <br />(multkply p 6y fee for <br />XX%X I XXXX I xxxx IxXXX I <br />I <br />I <br />I I <br />I g <br />A <br />each year applicable) XXXX <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I xxxx I <br />XXXX I xxxx I XXXX IxxxX I <br />I <br />L <br />5 <br />I <br />STATE SURCHARGE FOR NEN FACILITIES <br />ONLY=518.50 <br />I <br />S <br />T <br />Y <br />Tanks_ x 58.00 <br />i 1988 through 1993 (S56) <br />1993 through <br />1997 (S56) <br />1998 I <br />I <br />3 <br />SURCHARGE FOR 1998 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XxxxxxxxXxxxxxxxXxxxxxx <br />' <br />S <br />CI <br />LL <br />PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) <br />I TANK I.O. @(s) <br />OI <br />5 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK)I <br />1t TANK(s) X 5234.00 = <br />U <br />R <br />TEMPORARY CLOSURE (Plan Review 8 Inspections) <br />TANK I.O. N(5) <br />EI <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum FACILITY) <br />5234.00 minimum <br />PI <br />L <br />INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. H(s) <br />A <br />NI <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />- 5624.00 minimum <br />RI <br />EL <br />REPAIR FEE (Workplan Review 8 Construction Inspections) <br />I TANK I.D. :(s) <br />PI <br />A <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />I H TANK(s) X 5234.00 = <br />I 'TANK <br />R <br />RE7 ROFIT_, REPAiR FEE',`x. S78.00/hour (3 hours min -/FACILITY) <br />= 5234.00 minimum <br />PIPING REPAIR FEE = 578-00/hour (3 hours minimum/FACILITY) <br />= 5234.00 minimum <br />II <br />TRANSFER FEE= 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr i <br />S <br />=' <br />CONSULTATION FEE = 578.00/hr I I SAMPLING INSPECTION FEE <br />= 578.001hr <br />U0 <br />ONLY <br />LOC CODE DIST CODE I AMOUNT RECEIVED I CHECK :/CASH <br />S I <br />4 J'S nip IRFVISFO 1-12-98) <br />15 <br />TOTAL DUE 15 <br />