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SAN JOAQUIN Ca PUBLIC HEALTH SERVICES - ENVIRONMENTAL N� DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> S� FACILITY NAME ' <br /> I <br /> E FACILITY AD0 55 SITE PHONE X wi:h AREA CODE <br /> & j( TEI ZIP CODE j of TANKS ! <br /> 'IT <br /> f <br /> AI 1 G I ai SITE <br /> P <br /> Pi APPLI Ntn/ ILLING NAME-/ i APPLICANT NT i E <br /> t U/LX (�9L/C <br /> I .0 AP ICAN PX E C WITH AREA CODE 3 <br /> C, MAILING ADDRESS ��-�JJ(C�J�11 <br /> " o`� I <br /> Ni <br /> T` C:T7 ' AiE; ZIODa „J.,TYPE of APPLICATION <br /> j j (Closure, Instal lotion, etc-) <br /> TOTAL <br /> j j 1986 1 1967 1 7988 i 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> i Al xxxx j xxxx xxxx i xxxx I xxxx 9 S xx%x%XXX a <br /> E C <br /> ASSESSED XXXX XXXX X%xX XXXX XXXX S XXXXXXXxTFACILITY ?ENALcpp <br /> II ii Y: TANK FE. = 550.00/TANK (Prior to January 7,1991) i 5170/TANK (After January i, 7991) <br /> I c <br /> Tanks = 1987 j 1988 j 1989 11990 1991 1 1992 1993 1994 1995 1996 1997 9 <br /> F; (multioly by fee for <br /> AI each year apoLicabl e) I %XXX ' XXXX I XXXX I XXXX ';XXXX ! I i 5 <br /> C' <br /> I! TANK PENALTY FEES ASSESSED I XXXX XXXX I XXXX I XXXX iXXXX 5 <br /> L' <br /> Ii, STATE SURCHARGE FOR NEW FACILITIES ONLY = 518.50 i5 <br /> T' <br /> I T; I Tanks_ x 58.00 1988 through 1990 (556) 1991 through 1996 (S56)� 1997 <br /> I SURCHARGE FOR 1997 I xxxxxxxxxx%XXX%%%xxxxxxxXXX IXXXX%XXXX%XXXXXXXXXXXXX i O S y <br /> Ci PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK i.D. :(s) 1 <br /> L: <br /> TANK(S) X 5234.00 <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) N = S i <br /> 3 <br /> S,. <br /> UI TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. :(s) <br /> R' <br /> minimum/FACILITY); TEMPORARY CLOSURE F__ = 578-00/hour (3 hours minim /FACILITY) 5234.00 minimum 5 3 <br /> P; INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. N(s) i <br /> L; <br /> AI i <br /> N! PLAN CHECK F minimum/FACILITY)578.00/hour (8 hours minim/FACILITY) 5624.00 mini mum S <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) i TANK I.D. N(s) <br /> E j <br /> PI TANK LINING REPAIR FEE = 578-00/hour (3 hours minimum/TANK) X TANK(s) X 5234.00 <br /> Ij TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> 9 <br /> R <br /> minimum/FACILITY)REPAIR FEE = 578.00/hour (3 hours minim/FACILITY) = S23s.00 minimum S Zj QO I <br /> MI TRANSFER FEE = 520.00 I I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I S <br /> SI ! <br /> C; CONSULTATION FEE = 578.00/hr I I SAMPLING INSPECTION F7= = 578.00/hr IS <br /> TOTAL DUE S �j('�` • DO j <br /> FOR OFFICE USE ONLY <br /> swEEPS X I C0.MPUTER N lOC CODE I DIST CODE I AMOUNT RECEIVED CHECK :/CASH I RECEI VEO 3Y I DATE RECEIVED <br /> _ <br /> j <br /> EH 23 032 (REVISED 5-27-97) <br />