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SAN JOAQUIN as PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEIS DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />CONT <br />FACIL T���ACT �IAKE /Qum <br />F <br />FACILITY SITE NAME _ (n_ <br />�/ f S <br />SITE PHONE it with AREA CODE <br />FACILITY L1TY ADDRESS_ �_ n '41) q 'y& 9 _ ab( <br />✓-�`I`/ °' �-�d <br />b <br />STATE ZIP <br />CODE of TANKS <br />E <br />P TANK LINING REPAIR FEE = 578.00/hour (3 hours minim m TANK) <br />X TANK(s) X 5234.00 = <br />CITY <br />17J ;2 -d .J-at SITE <br />(//I <br />1TANK <br />PIPING REPAIR FEE = <br />A , b �/ <br />S/ C, <br />p <br />APPLICANT CONTACT NAME <br />P APPLICANT/BILLING NAME <br />�,I <br />L (�-YY1'�%I <br />APPLICANT PRONE <br />AREA CODE _ <br />I <br />C MAILING ADDRESS <br />/ <br />/d fWITH <br />�'• 3 _J / <br />d v <br />A 53Q �.P�1,ts-P.�l/o <br />P PLICATION <br />N STATE ZIP <br />CODE TTPE <br />TI CITY \ <br />I <br />Cl sur Installation, etc.) <br />�� <br />(J <br />TOTAL <br />1986 1987 11988 11989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />xXXX XXXX XXXX I <br />XXXX XXXX <br />S XXX%X%XX <br />%xxx XXXX nxx <br />%XXX %Xxx <br />S X%XX%XXX <br />T FACILITY PENALTY FEES ASSESSED (if Applicable) <br />1, 1991) <br />I(Prior 1,1991) I <br />5170/TANK (After January <br />V TANK FEE = 550.001TANK to January <br />1998 <br />E 1988 1989 1990 1991 11992 <br />1993 1994 1995 11996 11997 <br />X Tanks = <br />S <br />__ <br />F (multiply 9 by fee for <br />X%%X %X%X I %%XX I %%%% I%%XX <br />A each year applicable) <br />I <br />S <br />C I <br />1 TANK PENALTY FEES ASSESSED I XXXX %XXX I %XXX I %)(XX I)XXX <br />I <br />S <br />L <br />I STATE SURCHARGE FOR NEW FACILITIES ONLY=S18-50 <br />1998 <br />T 1988 through 1993 (556) <br />1993 through 1997 <br />(256) <br />Y � Tanks_ x $8.00 <br />XXXXXXXX%XXXXXXXXXXX%XX <br />S <br />XX%%XX%%XXX%%XX%XX%XXX%XXX% <br />SURCHARGE FOR 1998 <br />CLOSURE (Removal or Authorized Cl osure-in-Place) <br />TANK I.D. t(s) <br />C PERMANENT <br />tl TANK(5)� % 5234.00 <br />= <br />L <br />0 CLOSURE FEE = S78-DO/hour (3 hours mini nraNTANK) <br />I <br />5 <br />U TEMPORARY CLOSURE (Plan Review S Inspections) <br />TANK l.D. x(s) <br />R <br />= 578.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimm <br />S <br />E TEMPORARY CLOSURE FEE <br />INSTALLATION PLAN CMECX (Plan Review S Construction Inspections)I TANK I.D. X(s) <br />P <br />L <br />A = 5624.00 minimum <br />N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) <br />R REPAIR FEE (Workplan <br />Review B Construction Inspections) <br />TANK I.D. X(s) <br />E <br />P TANK LINING REPAIR FEE = 578.00/hour (3 hours minim m TANK) <br />X TANK(s) X 5234.00 = <br />A= <br />RETROFIT REPAIR <br />FEE = 578.00/hour (3 hours min./FACILITY) <br />5234.00 minimae <br />1TANK <br />PIPING REPAIR FEE = <br />578-00/hour (3 hours mini mm/FACILITY) <br />5134.00 minimae <br />= <br />NI TRANSFER FEE =_S20.00 <br />I: <br />CONSULTATION FEE = 578.00/hr <br />FOR OFFICE USE ONLY <br />Iii'vW ,irf 1i1J0iit!IIIiiEJ4ieilFu4r{ilma:T:mi <br />SUFFPS At I COMPUTER tl <br />FN n 047 (RFVISFD 1-12.983 <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />SAMPLING INSPECTION FEE = 578.001hr <br />CODE DIST CODE I AMOUNT RECEIVED I CHECK <br />S <br />S <br />S <br />S <br />S <br />1 S <br />TOTAL DUE7s <br />BY <br />IVED <br />