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SAN JOAQUIN COIA4aa PUBLIC HEALTH SERVICES - ENVIRONMENTAL NEM DIVSICIM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET `%w <br /> IS FACILITY SITE NAME FAC !TY CONTACT MIWE <br /> TAk se) <br /> 'E FACILITY ADORES � SITE PHONE N With AREA CODE <br /> LI lS 1 zy� 7d4 — F3e�'- W0f3 <br /> CITY � _ \ ATEP CODE # of TANKS <br /> 95e / <br /> A fJt-(a-- -fl' '� at SITE <br /> P <br /> P APPLICANT/BILLING E APPLICANT CONTACT NAME <br /> tTJ Ceryltyl uucij1 X 70ak1 AU.uc-,� k <br /> C MAILING ADDRESS S+r APPLICANT PHONE # WITH AREA CODE <br /> N SSl St ,tet' Z,o5 - 8'3y - 7DS �: <br /> T CITY l STATE ZIP CODE TYPE of APPLICATION C4-0!iu �L <br /> S �V CA CIS'3�iQ (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A XXXX XX%X X)IXX XXXX xxxx <br /> S xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx XXXX %XXX xxxx S xxxxxxxx <br /> V TANK FEE S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 11996 11997 1 1998 �G1C�q <br /> F (multiply # by fee for ^ <br /> A each year applicable) XM XXXX XXXX XXXX XXXX �1a� D'i O - '1O- 1110-7 O <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx XXXX xxxx xxxx XXXX I 1-10-1 110 1-10 1110: S 2 <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY-10 lo," S <br /> T <br /> Y # Tanks 1 x 38.00 1988 through 1993 (356) 1993 through 1997 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXxxxxxxxxxxxxxxX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) x 5234.00 = 5 <br /> _ a 3 <br /> 5 u G UV <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. N(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - S78.00/hour (3 hours minimum/FACILITY) 5234.00 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/FACILF?u minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE - S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I I <br /> 5 <br /> C1 CONSULTATION FEE S78.00/hr <br /> SAMPLING INSPECTION FEE 1= 578.00/hr I S <br /> FOR OFFICE USE ONLY TOTAL S <br /> Imm. S!_e!!!^t.Y1C:e�!!.ce—.�-F. :'myi�!¢..._'�'w.....°�aa^_5.?'.5�=...�_a icme_e_ __ u_m_,� __ <br /> v.._ ci:^iLSFulwi!:MPU i!m .3wu'euS!i!4aC 3ui3'nna44!G.'_-6r._-CBaa.=Si!!:AMOUN�r:eEEEIV4-_ii!�-_'!"�!2!!-4A!/CASH Wiz_�tis�. <br /> _ <br /> SWEEPS # COMPUTER N LOC CODE DIST CODE AMOUNT RECEIVED CXECK #/CASK RECEIVED gY DATE RECEIVED - <br /> irr . : � �::::::=, _+__,!,.___::,— <br /> .. w.:.!F.._._........._.._.a..............._........._._.:,:.._::..........._..__w_. <br /> FN 71 n'17 tRFV1SF0 1-12-98) <br />