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SAN JOAQUIN CCU PUBLIC HEALTH SERVICES - 91VIROMMDTAL HEAOIVSION <br /> UND CUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> Sl FACILITY SIT/E �NAM�,E// IATCONTACT NAME //•1 <br /> TI h O'GJCt ow L "A <br /> 'E FACILITY A00RESS 1 SITE PHONE with AREA CODE <br /> s /z 7v l� ��� If fav tzo5 �z7- <br /> i CITY /�_ ST E ZIP CODE I- of TANKS <br /> A l.1Zj-7 at SITE <br /> P <br /> LI APPLICANT/BILLING NAME APPLI T CONTACT NAME . <br /> C MAILING AD-01fESSAPPLICANT PHONE d WITH AREA CODE <br /> A �W7z7— <br /> CITY <br /> z7—CIT7 I STATE ZIP �� TYPE of APPLICATION La <br /> G I1LA �iJ (C:asur_, :rtttatlacion, etc.) <br /> TOTAL <br /> 1986 11987 ; 1988 11989 119911 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A I XKXX XXXX �, :Occx I Wool I x S XXXXXXXX <br /> fI FACILITY PENALTY FEES ASSESSED (If Applicable) I XX%X ' XXXX X)00f xw C= S XXXXXXXX <br /> '1j TANK FEE = 550-00/TANK (Prior Co January 1,1991) I 5170/TANK (After :angry 1, 1991) ' <br /> E. <br /> I X Tanks = I 1988 1 1989 I 1990 1 1991 1 1992 I 1993 I 1994 1995 1996I 1997 I 7998 <br /> Fj (multiply by fee for <br /> Al each year applicable) XXXX XXXX I XXXX I X)001 IXXXX <br /> C. I I I I S <br /> LI TANK PENALTY FEES ASSESSED XXXX I XXXX I XXXX I =a IXXXX I I I { ! S <br /> 11 STATE SURCHARGE FCR NEW FAMITIES ONLY=518.50 S <br /> YlTj —�l <br /> X Tanks_ x $8.00 1988 through 1993 (S56) 1993 through "997 (558) T998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXX)IX)IXXXX I XXXXXXXXXXXXX)ODDODOCa ! 5 <br /> Ci PERMANENT CLOSURE (Removal or Authorizer) Closure-in-Place) I TANK I.D. <br /> Ll <br /> J y <br /> SI <br /> CLOSURE FEE = 578.70/hour (3 hours minimm/TANK) ! TANK(s) I t <br /> U TEMPORARY CLOSURE (P(an Review 3 Inspections) I TANK 1.0. As; <br /> R <br /> El TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimim/FACILITY) I 5234.00 minima 5 <br /> i <br /> FA <br /> I INSTALLATION PLAN CHECK (Plan Review d Construction Inspections)ITANK I-D. C(5) <br /> PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br /> = 5624.00 minima 5 It <br /> RI REPAIR FEE (Workp(an Review 3 Construction Inspections) <br /> TANK [.o.4 (s) <br /> pTANK LINING REPAIR FEE378 00/hour (3 hours minima/TANK) I i TANK(s) <br /> % 5234.00 = i <br /> [ TANK RETROFIT REPAIR FEE = ) = 5234 GO minimum 578-UO/hour (3 hours min./FACILITY <br /> R � i <br /> I PIPING REPAIR FEE = 578.00/hour (3 hours mini <br /> mm/FACILITY) = 5234.00 minimum I <br /> S <br /> � <br /> ITRANSFER FEE = 520,00 I I UNAUTHORIZED RELEASEE EVALUATION = 578 00/hr <br /> S. <br /> I � 5 <br /> C CONSULTATION FEE = 578.00/hrSAMPLING I - <br /> INSPECTION FEE <br /> = 578.00/hr <br /> 5 <br /> -FOR_OFFICE USE_ONLY-- - TOTAL DUE g 7'z <br /> ;- EEPS x I CCMPU7ER S <br /> LOC CODE OIS7 <br /> CODE I AMOUNT RECEIVE] - - — - _ <br /> I CHECK A/CA <br /> SH e-'_ -�._-- <br /> 2EC.IVED 3Y I DATE RECEIVED^mss <br /> EH 23 032 <br /> (REVI SEU 1-12-98) <br /> Unrd�23 5 <br /> -y <br />