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SAN JOACUIN"TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH DIVSION <br /> RGROUND STORAGE TANK PROGRAM - FEE FORKS <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS I SITE PHONE 9 with AREA CODE <br /> CITY STATE ZIP CODE f N of TANKS <br /> A _* SZ�� II at SITE <br /> P APPLICANT/BILLING NAME APPL NTC TACT N <br /> L <br /> ! <br /> CMALI AOORE55 APPLICANT PHONE 9 WITH AREA CODE <br /> A <br /> N - D � � r � <br /> T CITY Cto <br /> STATE ZIP CODE TIP—,APPLICATION <br /> CA- Iasur Instal[anion, etc.) <br /> TOTAL <br /> 1 1 <br /> ANNUAL FACILITY FEE (prior to January 1, 1991) = 5100.00 3986 1987 1988 1989 1990 <br /> A <br /> C XXXX I XXXX I XXXX xXxx XXX% S XXXXXXXX <br /> f <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX xxxX I XXX% <br /> I f=1 )()= <br /> $ XXXXXXXX <br /> !! <br /> V TANK FEE = 350.00/TANK (Prior to January 3,1991) E 5170/TANK (After January 1, 1991) <br /> E, I <br /> + 9 Tanks = 1987 1988 1989 11990 11991 11992 1993 1994 11995 11996 11997 <br /> F (multiply by fee for I <br /> A each year applicable) XXXX XXXX xxxx XXXX XXXX 70� 0 0 170 .70 !10 Z O <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX I XXXX XXXX XXXX XXXX 70 I 701 70 I a I .7D I 0 <br /> L` V / I <br /> II STATE SURCHARGE FOR NEW FACILITIES ONLY = 518.508 <br /> T <br /> Y; 9 Tanks x 58.00 1988 through 1990 ($56) 1991 through 1996 (556) 1997 <br /> SURCHARGE PCR 1997 Xxxxxxxxxxxxxxxxxxxxxxxxxxx XXXXxxxxxxxxXxxxxxxXxxx 5 <br /> CPERMANENT CLOSURE (RemovaL or Authorized CLasure-in-Place) TANK I.D. :(s) <br /> L; <br /> O� CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I TANK(s) X $234.00 = S z,j? <br /> S <br /> UITEMPORARY CLOSURE (Plan Review & Inspections) TANK 1.0. ;*(s) <br /> Rl <br /> Ej TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 1 5234.00 minimum S <br /> Pl INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. ;O(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624:.00 minimum 3 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK F.D. *(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours miniaxW TANK) I TANK(s) X S234..00 = S <br /> A <br /> I <br /> R TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> Al TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr i S <br /> if <br /> S <br /> C; CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr # I g <br /> TOTAL DUE S 7 su/Z <br /> FOR OFFICE USE ONLY <br /> __....___.. ........._.._... .....--..... <br /> SWEEPS COMPUTER LOC CODE I DIST CODE AMOUNT RECEIVED CHECK k/G1SN RECEIVED gY 1 DATE RECEIVED _ <br /> I <br /> 5 <br /> _... .........__........_......_-.._.. •...-_._.._........._._..........._ <br /> ::::::::::::::,:::::::.:::::::::::•.::_::::: : s:::::— :::::M::::: _:: -. :::: :::::_:::::::: ::::= - w _=:=- :•T: _::::::::a-"__w s -::= -: :ss= €:mss ::�:-' : <br /> EH 23 032 (REVISED 5-27-97) <br />