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SAN JOAQUIN TT PUBLIC HEALTH SERVICES - ENVIRONMENTAL N �l DIVSION <br /> AM <br /> STORAGE TANK PROGR - FEE NORKSN <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> IG, <br /> T <br /> 'E FACILITY ADDRESS SITE PRONE X with AREA CODE <br /> CITY STATE ZIP CODE X of TANKS I <br /> A "4 ��Z/�/J at SITE <br /> P <br /> P AD1Y{PL ICANT/BILLI 6 NAM APPLICANT CONTACT MANE <br /> L 2^ <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE k WITH AREA CODE <br /> A Zl Z o cv LAX4 Vlf— <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX )(X)cX xxxx xxxx xxxx S XXXXXXXx <br /> C <br /> Tj FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX xxxx XXXX XXXX I XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> ETanks1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 <br /> F[;�-- <br /> g <br /> ultiplyfee forAch year applicable) x%XX I xxxx I xxxx XXXX (XXXX r7p I.7„ l7o / 7p I I7p ('7o s <br /> C� <br /> I TANK PENALTY FEES ASSESSED I XXXX I XXXX XXXX I XXXX (XXXX I (71111�7n 1110 I / 70 I17D I S /fTYJ✓�-1 <br /> L <br /> II STATE SURCHARGE FOR NEW FACILITIES ONLY-518.50 S <br /> T <br /> Y : Tanks z 58.00 1988 through 1993 ($56) 1993 through 1997 (556) 1998 <br /> SURCHARGE FOR 1998 I XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX { S <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.O. N(s) <br /> L <br /> 01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) ? TANK(5)_ X 1234.00 = 15 <br /> S <br /> Ul TEMPORARY CLOSURE (Plan .Review 3 tnspections) TANK 1.0. ;9(s) <br /> R <br /> ETEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5734.00 minimum S <br /> PFPLA <br /> ALLATION ?LAN CHECK (Plan Review i Construction Inspections)I TANK 1_0. %(s) <br /> L <br /> A <br /> N CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimtm S <br /> R REPAIR FEE (Workplan Review 3 Construction Inspections) TANK 1_0. S(s) <br /> E <br /> l I <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) N TANK(s) _ X 5734.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> NI TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I 5 <br /> I I I <br /> S' <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr I S <br /> TOTAL DUE S L,c. U <br /> FOR OFFICE USE ONLY <br /> - SWEEPS i* COMPUTER N LOC CODE DIST CODE AMOUNT RECEIVED I CHECK 4/CASH RECEIVED BY DATE RECEIVED <br /> EH 23 032 (REVISED 1-12-98) <br />