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' SAN JOAQUIN CLUNI tlLIC HLnLln SufY ILLS - G4YlwtMMLNinI ntn 1, Y>�Lw <br /> UNDER STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SI FACILITY SITE NAME I FACILITT CONTACT NAME lI OF71� y <br /> n <br /> -EFACILITY ADDRESS SITE PHONE with AREA CODE <br /> a o l m EN A42 e Y <br /> CITY TA E ZIP CODE A of TANKS <br /> p <br /> TD-A gall ac SITE <br /> P APp![CANT/8[CLING HANE APPLICANT CONTACT NAME <br /> t�N ty�R S C1' ( cSF Pel L e_ icc Kl P'l m <br /> C .9AILIyG ADORESS AP ICANT PHONE # WITH AREA CAE <br /> Al <br /> T CITY \ STATE ZIP CGOE I TY E of APPLICATION 4t '51-( 1��r-�� <br /> AW\`11 �L�a1 (Closure, Installation, etc.) <br /> v 1 TOTAL <br /> I I I <br /> ANNUAL FACILITY FEE (prior :o January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> A I XXXX XXXX I XXXX xxxx I XXXX S XXxxxxxx <br /> C <br /> TI FACILITY PENALTY FEES ASSESSED (If Applicable) I xxxx I XXXX xxxx I xxxx I xxxx I S XXXXXxxx <br /> I <br /> e� TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (Atter January 1, 1991) <br /> Tanks = 1988 11989 11990 1991 11992 11993 1 1994 11995 11996 11997 11998 I <br /> F (mulciplY by fee for <br /> A <br /> C each year applicable) I XXXX I XXXx I XXXX I XXXX XXXX I I I I I I S <br /> f TANK PENALTY FEES ASSESSED XXXX XXXX I XXXX I XXXX XXXX I I I I I S <br /> L' <br /> I STATE SURCHARGE FOR 4E'A FACILITIES ONLY=S18.5O S <br /> T : Tanks_ x 58.00 1988 through 1993 (156) I 1993 chraugh 1997 (156)+ 1998 I <br /> SURCHARGE FOR 1998 I XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX I I S <br /> C; PERMANE41' CLOSURE (Removal or Authorized Closure-in-Place) I TANK (.0. :(s) <br /> L' <br /> sI CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) : TANK(s) AL X 5234.00 I S �Z <br /> UI TEMPORARY CLOSURE (Plan .Review 3 Inspections) I TANK I.O. S(s) J <br /> RE I TEMPORARY CLOSURE FEE = 378.00/hour (3 hours minimum/FACILITY) I $234.00 mini mm S <br /> ` !HSTAILATION PLAN CHECK (Plan Review 3 Construction Inspections)I iAHK I.O. :(s) <br /> A <br /> N PLAN CHECK FEE = 378.00/hour (8 hours minim./FACMTY) = 5624.00 minio S <br /> R) .REPAIR FEE (WorkpLan Review 3 Construction Inspections) I TANK 1_D. X(s) <br /> c <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minim./TANK) 4 TANK(s) X 3214.00 5 <br /> A <br /> 11 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 1234.00 minimum I S <br /> R <br /> P(P!NG .REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 1234,00 minimum I S <br /> Mi TRANSFER FEE = S20.00 I I UNAUTHORIZED RELEASEE EVALUATION = S78.00/hr I I S <br /> Ii <br /> SI I 1 i 1 <br /> CI CONSULTATION FEES = 178.00/hr I I SAMPLING INSPECTION FEE = S78.c0/hr I I 5 <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS COMPUTER x I LOC CODE I DIST CCOE I AMOUNT RECEIVED I CHECK d/CASH RECEIVED gY DATE RECEIVED _ <br /> EH 23 032 (REVISED 1-1298) <br />