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SAN JOAQUINBLIC HEALTH SERVICES - ENVIRONMENTAL HEO DIVSION riG UN ROUND STORAGE TANK PROGRAM - FEE WORKSHEET I FACILITY SITE ME L L FACILITY CONTACT NAME E el 1987 T 1989 1990 'E FACILITY ADDRESS 1 Q SITE PHONE # with AREA CODE ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 S A A CITY STATE ZIP CODE # of TANKS xxxx � � 30 at SITE P S XX%%XXXX ` P APPLI CA T/BILLING NAME APPLICANT CONTACT NAME L i C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A N T I FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX T CITY STATE ZIP CODE TYPE of A ATION XXXXXXXX V TANK FEE = $50.00/TANK (Prior to January 1,1991,) (Closur Installation tc.) TOTAL P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = 878.00/hour (8 hours minimum/FACILITY) = $624.00 minimum $ 3 R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E 1986 1987 1988 1989 1990 LOC CODE P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 S A :................: ,:.—::::::... $ xxxx X%XX %XXX XXXX XXXX S XX%%XXXX A C PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ T I FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX %X%X XXXX XXXX XXXX S XXXXXXXX V TANK FEE = $50.00/TANK (Prior to January 1,1991,) $170/TANK (After January 1, 1991) E # Tanks = 4 1988 1989 1990 1991 1992 1993 1994 1995 1 1996 1 1997 1 1998 F (multiply # by fee for XXXX XXXX XXXX XXXX XXXX `j96 e� S --�-- A each year applicable) C I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ L T STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 7 S _ Y # Tanks_ x $8.00 1988 through 1993 (S56) 1993 through 1997 (856) 1998 SURCHARGE FOR 1998 XXXXxxxxxxxXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXX%XXXX%% $ C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) L 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(a) R — E TEMPORARY CLOSURE FEE = 878.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = 878.00/hour (8 hours minimum/FACILITY) = $624.00 minimum $ 3 R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E ............................... .............. ............ M SWEEPS # COMPUTER # LOC CODE P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S A :................: ,:.—::::::... $ I TANK RETROFIT REPAIR FEE = 878.00/hour (3 hours min./FACILITY) = $234.00 minimum S R ..................................._..................... .... __._........................................................... PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ M TRANSFER FEE = $20.00 I S C CONSULTATION FEE = S78.00/hr UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I I FS SAMPLING INSPECTION FEE = $78.00/hr A'-`" LLu. /99G !) P�yi/�S ,F/dre--ct„+-wC.Qy.� �--� �TOTAL DUE [L2361 --- FOR !' FOR OFFICE USE ONLY /C-tJ/ ,.�Gn c,��D. cI 7�P.�,n %-L --�J7n ) EH 23 032 (REVISED 1-12-98) V 0 ............................... .............. ............ M SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED u. :................: ,:.—::::::... $ ..................................._..................... .... __._........................................................... EH 23 032 (REVISED 1-12-98) V 0