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SAN JOAQUIN Cr" PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE" H DIVSION <br />U,ROUND STORAGE TANK PROGRAM - FEE WORXSN <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />T <br />&A At:AJT— MA -(t -T <br />ANAM76 H54G <br />1987 <br />11988 <br />'E <br />FACILITY ADDRESS SITE PHONE X with AREA CODE <br />TANK I.D. x(s) <br />1 757o A1007 l WILSo t cMV 2 Gq - 9p <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) = 5100.00 <br />A-D(.�-) <br />CITY TATE ZAP CODE x of TANKS <br />(�, "/S at SITE <br />P <br />P <br />P <br />APPLICANT/BILLING VAME <br />APPLICANT CONTACT NAME <br />I <br />Al40 6S �n� � EL2 <br />Ar/A1fsR RG <br />C <br />MAILING ADDRESS�^. <br />APPLICANT PHONE N WITH AREA CODE <br />N72,01 <br />01 ,6C Av <br />JAC4 <br />ZaI —114 3Z <br />XXXX <br />%XXX <br />T <br />CITYSTATE ZIP CODE TYPE of APPLICATION <br />TANK LINING REPAIR FEE = 578,00/hour (3 hours minimum/TANK) <br />5i (Ctosure, Installation, etc.) V-&NOU/}— <br />I <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) <br />TANK 1.0. %(s) <br />L <br />0 <br />1986 <br />1987 <br />11988 <br />1 1989 <br />1990 <br />TANK I.D. x(s) <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) = 5100.00 <br />$234.00 mini mm <br />s <br />P <br />INSTALLATION PLAN CHECK (PLan Review 8 Construction Inspections) <br />TANK I.D. %(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />A <br />S <br />%XXX <br />XXX% <br />XXXX <br />%XXX <br />XXX% <br />s XXXXXXXX <br />TANK LINING REPAIR FEE = 578,00/hour (3 hours minimum/TANK) <br />A TANK(s) _ X 5234.00 = <br />I S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= $234.00 mini mm <br />S <br />C <br />N <br />TRANSFER FEE = $20.00 1 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I <br />S <br />I <br />I <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />= 578.00/hr <br />{ S <br />XXXX <br />X%XX <br />X%XX <br />XXXX <br />X%XX <br />S XXXXXXXX <br />I <br />V <br />TANK FEE = 550.00/TANK <br />(Prior cc January 1,1991) <br />5170/TANK <br />(After <br />January 1, <br />1991) <br />E <br />I Tanks= <br />1988 1989 1990 <br />1991 <br />11992 <br />1993 <br />1994 <br />1995 <br />1996 <br />11997 <br />1998 <br />F <br />(multiply X by fee for <br />XXXX <br />XXXX <br />I <br />I <br />S <br />A <br />each year applicable) XXXXXXXX XXXX <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX XXXX I XXXX <br />I XXXX <br />(XXXX I <br />I <br />I <br />! <br />I <br />I S <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 <br />S <br />T- <br />7 <br />N Tanks x $8.00 <br />1988 through 1993 <br />(556) <br />1993 <br />through <br />1997 <br />(556) <br />1998 <br />SURCHARGE FOR 1998 <br />XXXXXXXXX%XXXXXXX%XXXX%XXX% <br />XXX%%XXXXXxxxxxxxXXXXXX <br />s <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) <br />TANK 1.0. %(s) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />a TANK(s)X 5234.00 = <br />rx7 <br />s �j� . <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review S Inspections) <br />TANK I.D. x(s) <br />R <br />EI <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 mini mm <br />s <br />P <br />INSTALLATION PLAN CHECK (PLan Review 8 Construction Inspections) <br />TANK I.D. %(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />= 5624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review 3 Construction Inspections) I <br />TANK I.D. X(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578,00/hour (3 hours minimum/TANK) <br />A TANK(s) _ X 5234.00 = <br />I S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= $234.00 mini mm <br />S <br />N <br />TRANSFER FEE = $20.00 1 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I <br />S <br />I <br />I <br />Si <br />Ci <br />CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE <br />= 578.00/hr <br />{ S <br />TOTAL DUE <br />S 2-3 u f oa <br />ONLY <br />CHECK S/CASH I RECEIVED BY I GATE RECEIVED <br />cN 71 n17 rRFVISFG 1-12-98) <br />