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SAN JOAOUIN COl1LIC HEALTH SERVICES - ENVIRONMENTAL HEAL..VSIOM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> 51 FACILITY SITE NAME /J ' <br /> T Z-0.QI /Tl/v <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> Z � Q <br /> 3 S TE ZIP E # of TANKS <br /> CITY 1� � at SITE 3 <br /> A ✓ <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILL N�Ml <br /> L <br /> I APPLICANT PHONE # WITH AREAE <br /> C MAILING ADDRESS <br /> M TYPE of APPLICATION <br /> T CITY (Closure, <br /> S A E 2[ CODE'/ (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1487 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 %XXX XXX% I XXXX XXXX XXXX S XXXXXXXX <br /> A <br /> Cxxxx xxxx xxxx xxxx xxxx S xxxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If App(icable) <br /> I <br /> Y TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 7989 1990 7991 17992 1993 1994 1995 11996 11997 1998 <br /> F (multiply # by fee for I 5 <br /> A each year applicable) XXXX X%XX xxxx %XXX X%XX <br /> 11 TANK PENALTY FEES ASSESSED I XXXX XXXX XXXX XXXX (XXXX I I I I I 5 <br /> L S <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br /> T <br /> Y # Tanks_ x 58.00 1988 through 1993 ($56) 7993 through 1997 (556) 1998 <br /> SURCHARGE FOR 1998 XXXX%XXXX%XXXXxxxxxxxxxxXXX XX%%%%XXXXXXXXX%XXX%XXX <br /> 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #<s) <br /> L I # TANK(s) X 5234.00 = s <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /> S TANK I.D. #(S) <br /> U TEMPORARY CLOSURE (Plan Review S Inspections) <br /> R S <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) S234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK 1.0. #(s) <br /> L <br /> A = 562400 minimus s <br /> M PLAN CHECK FEE = S78.00/hour (8 hours mini mum/FACILITY) . <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) I TANK I.D. #(s) <br /> E % S234.00 = s <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours mini mm/TANK) # TANK(s) <br /> A = 5234.00 minimum 5 <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour C3 hours min./FACILITY) <br /> R $734.00 minimum s <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mini mum/FACILITY) <br /> N TRANSFER FEE = S20.00 UNAUT ------------- <br /> HORIZED RELEASE EVALUATION = 578.00/hr <br /> I 5 <br /> 1 <br /> I � <br /> S = 578.00/hr s <br /> ClCONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL OUE 5 <br /> FOR OFFICE USE ONLY —.-- -- <br /> mT <br /> i <br /> SWEEPS # COMPUTER # LOC CODE I O15T CWE AMOUNT RECEIVED CHECK #/CASH RECEIVED dY DATE E <br /> ru 7i nS7 (RFV15F.0 1-12-98) <br />