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' SAM JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL HOIVSION <br /> u ' U GROUND STORAGE TANK PROGRAM - FEE WORKSHEE <br /> S FAC IL TY SITE NAME FACILITY CONTACT NAME <br /> a <br /> T <br /> -E FACILITY ADDRESS /� _ �J�,� / SITE PHONE 4 with AREA CODE <br /> ® / R elf CliLif i`C.� R,17 . <br /> CITY \n j STATE ZIP CODE 4 of TANKS <br /> A Sfo�, / C4 q5Afj at SITE <br /> P <br /> P APPLICANT/SILL IN NAME APPLICANT CONTACT NAME <br /> L Q� <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE 9 WITH AREA CODE <br /> N 3 ce °WY,c.Lc. 6�ot 577 - <br /> T CITY/' _ ST TE ZIP CODE I TYPE of APPLICATION <br /> �` PC- �p y'� (Closure, Installation, etc.) V <br /> C1 I/ -f V+'� TOTAL <br /> 1986 1 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = s100.00 <br /> A XXXX XXXX I XXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX 1 XXxX 1 xxxx XXXX i XXXX S XXXXXXXX <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E M Tanks = (70 = 1988 1 1989 11990 1 1991 1 1992 11993 1 1994 1995 1996 1 1997 1 1998 <br /> F (multiply 4 by fee far _ <br /> A each year appLicabLe) XXXX I %XXX I XXXX XXXX IXXXX 5 15101510 I$[0 sj- /Q 1y!0 S2660 <br /> 15, a �ral 5 <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX 5[p 5/�j 1�J/b 51 D <br /> L /A <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=E18.50 S gr SV <br /> T <br /> Y % Tanks, x 58.00 1988 through 1993 (S56) 1993 through 1997 (556) 1998 <br /> SURCHARGE FOR 1998 I XXXXXXXxxxxxxxxxXxxxxxxxxxx XXXXXxxxxxxxxxxxxxxxxxX s a*r 60 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. 4(s) <br /> L <br /> 0 CLOSURE FSE = 578.00/hour (3 hours minimua/TANK) 4 TANK(s)_ % 5234.00 = s <br /> s <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.O. 4(s) <br /> It <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) =234.00 mini m5 <br /> mum <br /> P1 INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK E.O. 4(s) <br /> L <br /> A <br /> N PIAN CHECK FEE _ =78.00/how (8 hours minimua/FACILITY) = 5624.00 minimum s <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.O. #(s) <br /> — <br /> E <br /> P TANK LINING REPAIR FEE _ =78.00/hour (3 hours minimnm/TANK) 4 TANK(s) _ X 5234-00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) _ =234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) _ =234.00 minimum s <br /> M TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I 1 s <br /> I � <br /> S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr s <br /> 76 <br /> lMQ�O/ # '�j dZt LP✓ 6c ' 2. S&/ <br /> a� 5 <br /> FOR OFFICE USE ONLY <br /> — ,.— =.. -gin __—_—.__'- <br /> SWEEPS 4 COMPUTER 4 I LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK 4/CASH I RECEIVED SY DATE RECE LVED <br /> EH 23 032 (REVISED—1-12-98) • • <br />