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E <br />SAM JOAQUIN COUk.IPl18LIC HEALTH SERVICES - ENVIRONMENTAL HFJq,0OIVSIGN <br />uwOFRc2m= STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAMES <br />(Removal or Authorized Ctosure-in-Ptace) I <br />1986 <br />1487 11988 <br />11989 <br />FACILITY CONTACT NAME <br />I <br />` <br />CLOSURE FEE = S78.00/hour (3 hours mininam/TANK) ` <br />B TANK(s)_ X 5234.00 <br />S <br />A <br />U <br />xxxx <br />T <br />'E <br />FACILITY ADDRESS <br />xxxx <br />xxxx <br />S Xxxxxxxx <br />C <br />3 <br />SITE PHONE x with AREA CODE it <br />R <br />E <br />TEMPORARY CLOSURE <br />5r <br />$234.00 mini" <br />! S <br />T <br />CITY <br />I xXXX <br />%%XX <br />STATE) <br />ZIP CODE <br />X of TANKS <br />A <br />C{,�,�.�/(�n� <br />� <br />/T!� <br />��.� <br />S170/TANK <br />I <br />at SITE / <br />1, 1991) <br />�� vi <br />(A <br />A <br />N <br />PLAN CHECK FEE = <br />P <br />LAPPLICANT/Q,ILLING <br />NAME <br />5 <br />E <br />X Tanks = <br />APPLICANTT� T NAME <br />1994 <br />1995 11996 <br />11997 <br />1998 <br />F <br />C <br />MAILING A/{7+�l <br />APPLICANT PHONE d 4UITH AREA CODE <br />A <br />ESS ��� <br />!y' <br />each year applicable) <br />XXXx xxxx xxxx nxx rm <br />I <br />'�Y/Uw 4?— <br />N <br />T <br />CITY <br />��' <br />S <br />C <br />I <br />ST�ATE <br />^7� <br />ZIP E TYPE of APPLICATION <br />3b(, (Closure, Installation, etc.) <br />I <br />L <br />I <br />,u,wL <br />C <br />PERMANENT CLOSURE <br />(Removal or Authorized Ctosure-in-Ptace) I <br />1986 <br />1487 11988 <br />11989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />CLOSURE FEE = S78.00/hour (3 hours mininam/TANK) ` <br />B TANK(s)_ X 5234.00 <br />S <br />A <br />U <br />xxxx <br />%XXX <br />xxxx <br />xxxx <br />xxxx <br />S Xxxxxxxx <br />C <br />R <br />E <br />TEMPORARY CLOSURE <br />FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 mini" <br />! S <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />I xXXX <br />%%XX <br />XXXX <br />%XXX <br />X%%X <br />S %XXX%XXX <br />I <br />V <br />TANK FEE 550.00/TANK <br />(Prior to January 1,1991) I <br />S170/TANK <br />(After <br />January <br />1, 1991) <br />A <br />N <br />PLAN CHECK FEE = <br />S78.00/hour IS hours miniauWFACILITY) <br />= 5624.00 minimum <br />5 <br />E <br />X Tanks = <br />1988 1989 1990 1991 11992 11993 <br />1994 <br />1995 11996 <br />11997 <br />1998 <br />F <br />(multiply X by tee for <br />A <br />each year applicable) <br />XXXx xxxx xxxx nxx rm <br />I <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED I <br />%XXX I XXXX xXXX %%%% (XX%X <br />I <br />I <br />5 <br />L- <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br />S <br />T <br />T <br />R Tanks x 38.00 <br />7988 through 1993 (S56> <br />1993 through 1997 (556) <br />1998 <br />SURCHARGE FOR 1998 <br />xxxxxxxXXXXxx%Xxxxxxxxx%XXX <br />XXXXXxxxxxxxxxxxxxxxxxx <br />S <br />C <br />PERMANENT CLOSURE <br />(Removal or Authorized Ctosure-in-Ptace) I <br />TANK I.O. %(s) <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours mininam/TANK) ` <br />B TANK(s)_ X 5234.00 <br />S <br />U <br />TEMPORARY CLOSURE <br />(Plan Review S Inspections) <br />TANK 1.0. #(s) <br />R <br />E <br />TEMPORARY CLOSURE <br />FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 mini" <br />! S <br />P <br />INSTALLATION PLAN <br />CHECK (Plan Review S Construction Inspections)I <br />TANK I.D. 1(5) <br />L <br />A <br />N <br />PLAN CHECK FEE = <br />S78.00/hour IS hours miniauWFACILITY) <br />= 5624.00 minimum <br />5 <br />Ml TRANSFER FEE = S20.00 1 1 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr I 1 1 3 1 <br />I <br />CONSULTATION FEE = S78.00/hr <br />FOR OFFICE USE ONLY <br />SWEEPS x I COMPUTER X I LOC <br />FN Ji nil (RFVISFD 1-12-98) <br />SAMPLING INSPECTION FEE = 578.00/hr I i S <br />TOTAL DUE i S <br />AMOUNT RECEIVED CHECK x/CASH I RECEIVED BY I DATE RECEIVED <br />5 L <br />