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SAN JOAQUIN COUI111UBLIC HEALTH SERVICES - EHVIRoWEATAL HEALMIVSION <br /> UND�ND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILLTY CONTACT NAME <br /> I <br /> T <br /> 'E FACILITY ADDRESS SITE PHONE M with AREA CODE <br /> 3 <br /> 61 I> 9, OAK 7- <br /> CITY STATE ZIP CODE X of TANKS / <br /> A 017 y�O at SITE <br /> P <br /> P APPLICANT/BILL[ G NA APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE X WITH AREA CODE <br /> AZ Lv w . LGYJ VTfl. <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, trstallation, etc.) <br /> - <br /> : TOTAL <br /> ri. <br /> 1986 11987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) � 5100.00 <br /> A xxxx xxxx XXX)( xnx %XXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx XXXX I xxxx xxxx- <br /> %XXX S XXXXXXXX <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> X Tanks = �__ 1988 11989 1990 1991 1992 1993 11994 1995 1996 1997 1998 <br /> F (multiply X by fee for <br /> A each year applicable) xxxx X%X% xxxx xxxx XXX% 170 171, 17V 1170 )7o I17o S <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX I XXXX XXXX XXXX (XXXX 1170 I 1-7P I110 1170 I-7D 17O S IV(JU <br /> L--;-- <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY-SIS.50 I <br /> T <br /> Y X Tanks_ x 58.00 1988 through 1993 ($56) =1 <br /> 993 through 1997 (556) 1998 <br /> SURCHARGE FOR 1998 I xxxxxXxxxxxxxxxxxxxxxxxxxxx xxxxx"XXXXXXX%XXXXXXXX 5 <br /> C PERMANENT CLOSURE (Removal or Autharfzed Closure-in-P(ace) TANK 1.0. X(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) X TANK(s)_ X 5234.00 = S <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.O. X(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review d Construction Inspections) TANK I.D. X(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimun/FACILITY) 5624.00 minimum S <br /> R REPAIR FEE (Workp(an Review 8 Construction Inspections) TANK I.D. X(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) X TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hrI I S <br /> I <br /> Sl I I I I <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr I I S <br /> TOTAL DUE so DC fa <br /> FOR OFFICE USE ONLY <br />'. ias::c n ai�ldtialE'c:lE!'e"u:bsai —�. - <br /> SWEEPS X COMPUTERS LOC CODE DIST CODE AMOUNT RECEIVED I CHECK */CASH RECEIVED BY_.. DATE RECEIVED �fy <br /> EH 23 032 (REVISED 1-12-98) <br />