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SAN JOAQUIN CQM" 'KIBLIC HEALTH SERVICES - ENVIROINIENTAL HEAL" DIVSION <br /> UNDE%�,,AUID STORAGE TANK PROGRAM - FEE WORKSHEET `o, <br /> SFACILITY SITE NAME FACILITY CONTACT NAME <br /> I � 1 T <br /> T <br /> E FACILITY ADDRESS t7 SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS I <br /> A C at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> A MAI G AD�R�� �� ve S+Y APPLICANT PRONE # WITH AREA CODE <br /> N <br /> T CITY 13 9 / 1U, b q SS STATE ZIP CODE TYPE of APPLICATION ]e C k X2.5 <br /> / (Closure, Instaltation, etc.> q� <br /> "rti ". Z TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A XXXX )OXX XXXx XXXX xXxx $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If AppLicable) XXXX XXXX XxXx XXXX XXXX S xxxxxxxx <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1987 1988 1 1989 1990 1991 1992 1993 1994 1995 1 1996 1 1997 <br /> F (multiply # by fee for _ <br /> A each year applicable) XXXX XXXX XXXX xXxx XXXX S D <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ '� <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 �$ <br /> T � <br /> Y # Tanks x $8.00 1988 through 1990 ($56) 1991 through 1996 ($56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXxxxxxxxxxxxxX XXXXXXXXXXXXXXXXXXXXXXX 00,0 $ S� 00 l7 <br /> C PERMANENT CLOSURE (Removal'or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/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 = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimm/FACILITY) = $234.00 mini" $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> 1 <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE ANOINT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> ___ ... <br /> ............... _................ <br /> ....... _..._..__ __.__._...__.. _ <br /> EH 23 032 (REVISED 5-27-97) savjw- <br />