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SAN JOAQUIN C0� PUBLIC HEALTH SERVICES - ENVIRONMENTAL H�OIVSION <br /> ..*R <br /> N ROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITT SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> � q ,rte !,6 <br /> All <br /> A S <br /> CITY, STATE ZIP CODE # of TANKS <br /> ktl �^�,, <br /> P `A SZ.(]3 at SITE <br /> P APPLICANT/BILLING NAME <br /> L APPLICANT COIyTACT N <br /> �. <br /> I <br /> 1 7 <br /> C MfLI7ADDRESS / APPLICANT PHONE # UITH AREA CODE <br /> T CSTATE ZIP CODE TYP APPLICATION <br /> CA- g,SZQZ., [asur , Instal[ation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> A XXXX XXXX ' XXXX XXXX XXXX $ XXxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX xxxx XXXX XXXX XXXX S xxxxxxxx <br /> Y TANK FEE _ $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> 0 Tanks = 1987 1988 1989 1990 1991 1992 1993 1994 11995 1996 1497 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx xxxx xxxx xxxx xxxx 0 I 70 <br /> $ p �.O <br /> C 70 L2-0 I 179 <br /> TANK PENALTY FEES ASSESSED XXX <br /> XXXX XXXX XXXX XXXX 70 7V`� / 72 O $ /0 <br /> 7� <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 <br /> 7 / / is <br /> Y # Tanks x $8.00 1988 throughE1990E($56) E�1�991thr�ough 1996 (S56) 1997SURCHARGE FOR 1997 XX)DIXXXXXXXXXXXXXXXXXXXXXXXXxXxxxXXXXX $ I <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-P Lace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) x S234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br /> S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = 5624.00minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour 0 hours minimum/TANK) # TANK(s) <br /> A X $234.00 = S <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br /> R IS <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br /> I $ <br /> S <br /> C� CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY Ll n <br /> I: . <br /> _.................._......::::::::::::::::.:::::::::::::::::::�:::::::::::::-:::_•:::::::::::-::::: ::::::: ::::_.__::::::=: ::::::: :_ :: •:-__= :_a::::-:::::=s::rr:=:::-as tt!t¢:-¢s¢a_t a:=sss;: <br /> "" SWEEPS # ! CCMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY 1DATE REEEIVED <br /> :::::::::::::_::::::::::: :::aa°:: s::::::::::: :::::_::::at s:::::_::::_::: ..._...... :::::::::::::::::::::a <br /> EH 23 032 (REVISED 5-27-97) ............................. <br />