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SAN JOAQUj-'6FJNTT PUBLIC HEALTH SERVICES - ENVIRONMENT TN aIVSICM JWERGRCUND STORAGE TANK PROGRAM - FEE WCRW S FACILITY 317E NAME FACILITY CONTACT NAME I NI I T S 6 Z IJ'D 5 XXXXXXXX A I )DOC( I Xxxx ` %XXX IXXX)( E FACILITY ADDRESS f SITE PHONE : with AREA CODE I & P A I Tj I CITY STATE ZIP CODE R of TANKS IILJvIr A P S XX%XXXXX at SITE P APPLICANT/BILLING NAME APPLICANT CONTACT NAME L E I Al TRANSFER PEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr i Tanks = 11987 11988 1989 11990 11991 'cy 11992 11993 11994 1995 11996 11997 C MAILING ADDRESS (multiply + fee for each year appli Cable) )0= I %XXX XXXX I XXX% IXXXX APPLICANT PHONE 9 WITH AREA CODE A S G N I L. TANK PENALTY FEES ASSESSED %X%X %XXX XXXX XXXX XXXX I I I I I I � I I T CITY I STATE ZIP CODEI TYPE of APPLICATION (Closure, Installation, etc.) TOTAL P L INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) 1986 1987 1988 1 1 1 1989 1990 NI PLAN CHECK FEE - 578.00/hour (8 hours minimm/FACILITY) ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 i S 6 Z IJ'D 5 XXXXXXXX A I )DOC( I Xxxx ` %XXX IXXX)( XXXX C TANK 1.0..(s) P A TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) Tj I FACILITY PENALTY FEES ASSESSED (If Applicable) I xXXX I )0= I XXXX I — XXXX XXXX S XX%XXXXX V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) S E Al TRANSFER PEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr i Tanks = 11987 11988 1989 11990 11991 'cy 11992 11993 11994 1995 11996 11997 G ��, U -d F A (multiply + fee for each year appli Cable) )0= I %XXX XXXX I XXX% IXXXX I I j I(�J S G I L. TANK PENALTY FEES ASSESSED %X%X %XXX XXXX XXXX XXXX I I I I I I � I I 5 I• T STATE SURCHARGE FOR NEW FACILITIES ONLY - $18.50 p �S. j J 5o 7 T Tanks x 58.00 1988 through 1990 (S56) 1991 through 1996 (S56)� 1997 SURCHARGE FOR 1997 XXX%XXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX)WWXXXXXXX i 7-1)� LIPERMANENT CLOSURE (Removal or Authorized Closure -in -Place) I TANK I.O. 3(s) SI CLOSURE FEE = 378.00/hour (3 hours minimm/TANK) I TANK(s)_ X 5234.00 = I S 70 2 OU I Ui TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.O.:(s) 1 Ri E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimun/FACILITY) I 5234.00 minimum I S P L INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D..C(s) NI PLAN CHECK FEE - 578.00/hour (8 hours minimm/FACILITY) 5624.00 minimum S 6 Z IJ'D R E REPAIR FEE (Workplan Review & Construction Inspections) I TANK 1.0..(s) P A TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) Y TANK(s) X 5234.00 = S I R TANK .RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S PIPING REPAIR FEE = 578.00/how (3 hours minimum/FACILITY) = 5234.00 minim, S Al TRANSFER PEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr i S Ci CONSULTATION FEE = 578.00/hr I I SAMPLING INSPECTION FEE = 578.00/hr TOTAL DUE ! S OFFICE USE ONLY _'_ SWEEPS CCMPUTER t I LOC CCDE I DIST CODE j AMOUNT RECEIVED CHECK S/CASH RECEIVED 3Y DATE RECEIVED i€ €? EH 23 032 (REVISED 5-27-97)