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+ SAN JOAQUIN dyfY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HIS09H DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME _ FACILITY CONTACT NAME <br /> I L -4 <br /> T <br /> E FACILITY ADDRESS SITE PHONE S with AREA CODE <br /> a <br /> L 7-og— focp 2.82 <br /> CITYc STATE ZIP CODE 9 of TANKS <br /> A V'�� Ci( <br /> at SITE <br /> P <br /> P APPLICANT/BILLING NAME ` APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS APPLICANT PX X WITH AREA MOE <br /> 30 o Zoo - 86s- Zoo - ��x� Z3 <br /> T CIT G STATE ZIP CODE TYPE of APPLICATION C-Lwv v- <br /> `)am 1' ( a (Closure, Installation, etc.) -r+�p� , <br /> TOTAL <br /> 1986 1987 11988 1989 11990 <br /> ANNUAL fACILiTY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX X)OX XXXX S 100C<XX:CI <br /> C <br /> T FACILITY PENALTY FE-=S ASSESSED (If Applicable) XXXX X)= XXXX I XXXX )OW S XXXX)=X <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E X Tanks = _ 1987 11988 11989 1990 1991 11992 11993 1994 1995 1996 1997 <br /> F (multiply at by fee for <br /> A each year applicable) XXXX XXXX XXXX X)= XXXX ' S <br /> C <br /> I TANK PENALTY FE-=S ASSESSED I XXXX XXXX XXXX XXX)( )00(X I I S <br /> L <br /> I STATE SURCHARGE _ <br /> T <br /> Y # Tanks x 58.00 1988 through 1990 (556) 1991 through 1996 (S56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXX)OCCXXXXXXXXXXXXXX XXXxxxxxxxxxxxxxxXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. X(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) 9 TANK(s)_ X $234.00 = S <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review a Inspections) TANK I.D. X(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours mininun/FACILITY) I 5234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review d Construction Inspections) TANK I.O. X(s) <br /> L <br /> AlMPLAN CHECK FEE = 578.00/how (8 hours minimum/FACILITY) $624.00 minimum S <br /> R REPAIR FEE (Workplan Review a Construction Inspections) I TANK I.D. X(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) 0 TANK(s) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours miniaum/FACILITY) = 5234.00 minimum S <br /> NJ TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I <br /> S <br /> L CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S-Z �•/ 'LA- <br /> FOR OFFICE USE ONLY <br /> SWEEPS d CCMPUTER N LOC CODE I DIST CODE ' AMOl1NT RECEIVED CHECK 4!/CASH RECEIVED gY DATE RECEIVED <br /> S <br /> -cH 23 032 (REVISED 5-27-97) <br />