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SAN JOAQUIN (X)UPIIBLIC HEALTH SERVICES ENVIRONMENTAL IVSION UNDERGROUND STORAGE TANK PROGRIU4 - FEE WORKSHEET S FACILITY SITE NAME FACILITY CONT CTMAKE �i y T 'E FACILITY ADDRESS SITE PHONE # with AREA COOS IliqZ [' q6 S ` CITY STATE ZIP CODE # of TANKS A �� Tom'1 CkW ��--� at SITE CJ CJ tA�r �i�� P APPL[CA BILL]NG NAME 7 /" APP IC�lANT CONTACT NAME L l C U) - I Cs SI-74-Trol�l C ILING ADDRESS APPLICANT PHONE it WI AREA CODE N T CITY STATE ZIP CODE �=nstaiiation, LICATION etc.) l_+ TOTAL PXI 861987 1988 1989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100,00A XX XXXX I XXXX %XXX LXXk 5 %XXXXXXX C T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXX% LXXXLXXX S kXXXXXXX I - V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1941) E I Tanks = 1488 1989 1990 1991 11992 1993 1994 1995 11996 1997 1998 F (multiply # by feefor A each year applicable) LXX% LXXX XX%X X%XX XXXk 5 C I TANK PENALTY FEES ASSESSED XXXX %XXX I XXXX XXXX XXXX I 5 L I STATE SURCHARGE FOR NEW FACILITIES ONLY=s18.50 5 T Y # Tank& x 38.00 1988 through 1993 (556) 1993 through 1997 (556) 1998 SURCHARGE FOR 1998 XXXXXXXXX%XXXXXXXXXXXXXX%XX XX%XXXXXXXXXXXXX%XXXXXX s C PERMANENT CLOSURE (Removal or Authorized Closure-in-P Lace) TANK I.D. #(s) L _ 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)—f - X 5234.00 S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) R E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234,00 minimum 5 P INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) - S624.00 minimum 5 R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK i.0. #(s) E P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234,00 S A 4 I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum 5 R PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S I S C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S TOTAL DUE s FOR OFFICE USE ONLY _..._ .....»........ ......i.,i.__—_.x...l..r..lrn..:r..rsnn==.._...__—.___ :•'»"�—:......__us:.».::.:......._:::cc::ic: :rss .. jr- ME SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK ;*/CASH RECEIVED 3Y DATE RECEIVED i as .i: .. .�.._.__........_.. _...._._.........__.____.............._ .__..-.._:._......«-.... Y»......._....._....». t»_.._._«....._....- »....,....r._.-._.....- ME rw 71 n17 (RFVISFD 1-12-98)