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A SAN JOAQUINPUBLIC HEALTH SERVICES - ENVIRONMENTAL H IVSION <br /> U a1N0 STORAGE TANK PROGRAM - FEE WORKSH `. <br /> S FACILITY SITE NAME FACILITY CONTACT NAME 0,4S''f� <br /> I 1 G <br /> T SITE PHONE % with AREA CODE <br /> 'E FACILITY ADDRESS /J Rd <br /> "7 J <br /> CITY ^ STATE ZIP CODE X of TANKS <br /> A J at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I ,� I APPLICANT PHONE X WITH AREA CODE <br /> C MAILING ADDRESS /3 .: "�.'ll <br /> A `� W6 <br /> N <br /> T CITY STATE 2 P CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 7986 11987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A %XXX XXXX %XXX %XXX XX%X S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicahle) XXXX I XXXX I %XXX X%XX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to Janus 1,1991) 5170/TANK (After January 1, 1991) <br /> 0 Tanks i988 1 9 Viggo 1 X%1 1 2 4 . 1 96 1 1 97 1 1998 <br /> (=LtipLy * yfee <br /> o�� <br /> A each year bXXXX %XXI XXXX I XX XXX% 161176I75 <br /> I TANK PENALTY FEES ASSESSED I XXXX I X XXXX I )LXXX IaXX <br /> 117v o 1611 1011145 _ <br /> L /I STATE SURCHARGE FOR NEW FACILITIES 0 Y=S7 50 S <br /> T <br /> Y X Tanks x $8.00 19 ihr gh 1993 (556) 1993 thraugll .1947 ($56) 7996 <br /> raM,K J $ <br /> SURCHARGE FOR 1998 %XXXXXXXX%S(XX %XXXXXK XXXXXXXXXkXXXXXXXXXXXX% <br /> C PERMANENT CLOSURE ( aL o Authorized Ctosure-in fla ) ,4/TANK E.D. #(s) <br /> L <br /> 0 CLOSURE FEE - 8.00/hour (3 hours minimm/TANKy3 ( Y TANK(s)_ X 3234,00 5 <br /> 5 ! <br /> U TEMPORARY CLOSURE (Plan iew & Inspection) TANK I.D. x(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/how hour mi nimm m <br /> /FACILITY) .00 mini <br /> P INSTALLATION PLAN CHECK (P(an Rev Construcitnspeetiens)) TANK I.?, A(s) <br /> L <br /> A <br /> N PLAN CHECK FEE 578.00/hour (8,hours minimm/FACILITY) - 5624.00 nimm <br /> R REPAIR FE=_ (Workplan Review & Construction Inspections) I TANK I.O. <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) TANK(s) % 234. - S <br /> A <br /> I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minirtAan/FACILITY) = 5234.00 minimm S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr 5 <br /> I � <br /> 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = $78.00/hr S <br /> ,L� AL DUE <br /> �/) <br /> FOR OFFICE USE ONLY ��^'""v`-' w`T/�/ " �l - - <br /> SWEEPS x� COMPUTER Y !OC CODE GIST CODE AMOUNT RECEIVED I CHECK +/CASH RECEIVED SY DATE RECEIVED <br /> EH 23 032 (REVISED 1-12-98) <br /> AA)K � ule� ecoc�vw�e o� Bill 6�(ah - -y-U 0f "%VT.A <br />