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SAN JOAQUIN C(M PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEjW DIVSION (b C.SG - ,. �. ^ UNIWROUND STORAGE TANK PROGRAM - FEE WORKSHEE S FACILITY SITE NAME FACILITY CONTACT NAME I T 'E FACILITY ADDRESS SITE PHONE # with AREA CODE & -5458 CITY STATE ZIP CODE # of TANKS A at SITE P P APPLICANT/BILLING NAME APPLICANT CONTACT NAME L I /J C MAILING ADDRESS IT' \ APPLICANT PHONE # WITH A CODE A /i N T CITY / � STATE ZIP CODE TYPE of APP CATION (Closure, nstallat ion, etc.) V—' TOA Q� l ANNUAL FACILITY FEE (Prior to January 1, 1991) _ 1986 T 767 1988 1 1989 1 1990 AXXxX XXXX XXXX xxxX XXXX $ XXX%XXXX��e-* C T FACILITY PENALTY FEES ASSESSED (If Applicable) ✓ X% 1 x%%X XXXX xX%X XXX% S XXXXXxxx I V TANK FEE = $50.00/TANK (Prior to January 1,1991) $170/ ANK (After January 1, 1991 W.* E # Tanks = 1988 1989 1990 1991 1992 19y"I1994 1 1995 1 1996 1 1997 1998 V,�lh/ 5') �3�• F (multiply # y fee for A each year applicable) XXX% XXX% X%xX XXXX XXXX $ ( O I TANK PENALTY FEES ASSESSED %XXX XXXX XXXX %XXX %%%X l ( $ L I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 Y # Tanks_ x $8.00 1988 through 1993 $56) 1993 through 997 (856) 1998/' 5'1��C6 SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXxX X%XXXX %XXXXxxxxx XXXXXXXXXX $ \ C PERMANENT CLOSURE (Removal or Authorized Closure In-Place) TANK I.D #(s) L 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/T K) # TAN (,) X $234.00 = $ 2 300 -to S w U TEMPORARY CLOSURE (Plan Review & Inspecti0 ) :e I.D. #(s) �_ W R E TEMPORARY CLOSURE FEE _ $78.00/hour (3 h urs minimum/FACILITY) $234.00 minimum S P INSTALLATION PLAN CHECK (Plan Revie & Construction Inspect' ns) TANK I.D. #(s) L A N PLAN CHECK FEE _ $78.00/hour (8 ours minimum/FACILITY = $624.00 minimum $ R REPAIR FEE (Workplan Review Construction Inspec ons) TANK I.D. #(s) E P TANK LINING REPAIR FEE = 8.00/hour (3 hours nimum/TANK) # TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR F = $78.00/hour (3 hrs min./FACILITY) _ $234.00 minimum $ R PIPING REPAIR FEE = 78.00/hour (3 hours inimum/FACILITY) _ $234.00 minimum S N TRANSFER FEE $20.00 UN UTHORIZED RELEASE EVALUATION = $78.00/hr $ I S C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ TOTAL DUE $ Q'Z FOR OFFICE USE ONLY vv ::::::::: ::::::::::::::::: ::::::::::::::::::::::::.:!:::tt::::ttta:e::aa _.: e :::::::::::::::::::::::::[[[[[:'_:[-[-:[[iiii i iii!!:':t'iiia: tr ;;i i iiiii ii........................i st[t[::::t[:tt[t[t[:tttt:[t[ta::::::: :::rr:r.=.t:`:t:t:t_ ............................ :t:......................................................::::........._.__.__...:_._......._:...:............_......:::.:::.........:.................:..___:.:__:_::._.........:�.....____:__:_................. SWEEPS # COMPUTER # LOC CODE 01ST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED $ unarmatunn M. .. ...................................�:.. ._._.._...,_:::.::,P._:..:_:::,::::::::::: ................::: .........................::........_........................................................................................__....._..__..._.._.._.....T................................................... EH 23 032 (REVISED 1-12-98)