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• SAN JOAOUIN Cr Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL Hr -H DIVSION <br /> U. 1ROUND STORAGE TANK PROGRAM - FEE WORKSHEE <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & e. <br /> CITY STATE ZIP CODE # of TANKS <br /> F S7GG�7• 4 q5 AC7 at SITE 3 <br /> P APPLICANT/BILLING NAME//,,�� APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESSAPPLICANT PHONE # WITH AREA CODE <br /> N RG. Qo 13 6v <br /> T CITY ) STATE ZIP CODE TYPE of APPLICATION ck;rq- e <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 8100.00 <br /> A %XXX Xxxx xxXx XXXX XXXX 8 xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX XXX% %XXX %XXX X%xX 8 Xxxxxxxx <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 7996 1997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XxxXX%%% x%xx $ <br /> C i <br /> I TANK PENALTY FEES ASSESSED xxxx XXX% XXXX xxXx Xxxx 8 <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18; 9. 10.Co S <br /> T <br /> Y # Tanks_ x 88.00 1988 through 1993 (856) 1993 through 1997 (856) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXxxxxxxxxxxxxxxXXXxx XXXXxxxxxxxxx%xxxxxxxxX $ <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)aX 8234.00 = 8 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <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 8 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 878.00/hour (3 hours minimum/TANK) # TANK(s) X 8234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 878.00/hour (3 hours min./FACILITY) = 8234.00 minimum 8 <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 8234.00 minimum 8 <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 878.00/hr 8 <br /> I <br /> -C I CONSULTATION FEE = 878.00/hr SAMPLING INSPECTION FEE = 878.00/hr 8 <br /> TOTAL DUE SAO ©� <br /> FOR OFFICE USE ONLY _ _ _ _ _ <br /> __ _ =iiliii - - iiiii'i. ��ii__Miiiiiii_-X11'':=i:iii - '--- ___ __ _ _ _ ,_____ ___--_..:_- <br /> 3. SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> in <br /> 8 <br /> ........................................_... i��..�.: .._... _ .. .-...;.. _ _ �... N.MUM:____ '__ <br /> :14 is <br /> is; <br /> is <br /> EH 23 032 (REVISED 1-12-98) <br />