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SAN JOAQUIN STY PUBLIC HEALTH SERVICES - ENVIRONMENTAL �7H DIVSION <br /> RGROUND STORAGE TANK PROGRAM - FEE WORKS HE <br /> S FACILITY SITE NAME <br /> I _ FACILITY CONTACT N ME <br /> T <br /> E FACILITY ADORE55 SITE PHONE # with AREA CODE <br /> & �o � aoq —ZQ <br /> S <br /> A CITY (3,_(_ G <br /> ,© �� STATE Z _COpET� # of TANKS <br /> P / C//7l VOO�II)U at SITE <br /> P APPLICANT/BILLING� NAME <br /> L w ' APPLICANT CONTACT NAME <br /> I 5 <br /> C MAILING ADDRESS <br /> A APPLICANT PHONE # WITH AREA CODE <br /> l : <br /> N <br /> T CITY �( STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 8100.00 1986 1987 1988 1989 1990 <br /> A <br /> C X%XXXXX% XXXX XXX% XXXX 8 %XXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXX% XXXX %XXX XXX% XXX% $ %XXXXXXX <br /> 1 <br /> V TANK FEE = 850.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = L1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 <br /> F (multiply # byfee for <br /> A each year applicable) %%XX XXXX XXXX XXX% ' 7D 8 <br /> CI TANK PENALTY FEES ASSESSED XXXX XXXX XXX% XXXX 8 <br /> L T <br /> 1 STATE SURCHARGE FOR NEW FACILITIES ONLY = 818.50 I8 �D <br /> T <br /> Y # Tanks_ x 88.00 1988 through 1990 (856) 1991 through 1996 (856) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXX%%XXXXXXX%XXXXXXXXX B•0 g <br /> 0 <br /> C PERMANENT CLOSURE (Removal-'or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) <br /> S X 8234.00 = $ <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = 878.00/hour (3 hours minimum/FACILITY) 8234.00 minimum 8 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D- #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 878.00/hour (8 hours minimum/FACILITY) = 8624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) <br /> A X 8234.00 = g <br /> T TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum g <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = $234.00 minimum 8 <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr 8 <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr g <br /> TOTAL DUE $ �0 <br /> FOR OFFICE USE ONLY <br /> _ <br /> WEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> S <br /> EH 23 032 CREVISEO 5-27-97) �YW ��Liit..�/I .. �i��%� .e•:�=:_:_ <br />