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SAN JOAQUIN a PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE DIVSION <br /> UNC AROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> �S FACILITY SITE, NAME FACILITY CONTACT NAME <br /> E FACILITY ADDRES SITE PHONE # with AREA CODE <br /> & 0C1 (-2o 1-1 It f-- 3� <br /> CITY STATE ZIP CODE # of TANKS <br /> A �j � L��,u at SITE <br /> P <br /> P APPLICANT/B,J,LI�ING NAME APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A c � <br /> N � 4vl <br /> T CITY STATE ZIP CODE TYPE of APPLICATION A <br /> f`� �j�✓(`. 6a (Closure, Installation, etc.) <br /> V TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) TOP <br /> E <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 '. <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX , 10 j'7 L� ! � 17� U r^ 4'6 $ 01W <br /> C <br /> ITANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX i' r 70 /10 3 1 L-) 6 $ I),Oo <br /> L � <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 $ �d, 6,9 <br /> T <br /> Y # Tanks—L x $8.00 1988 through 1993 ($56) 1993 through 1997 ($56) 1998 I <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXySa $ 9 60 <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /> RREPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = I $ <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum ( $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr I $ <br /> TOTAL DUE S ' <br /> FOR OFFICE USE ONLY <br /> .................................................... <br /> ..........................................ssi;'si i ii's €s's€i s i€ iiiiEi 's; 'sii'€€€€;ii 'siii:tisi::::s:: sss::s :::::......::s............:::...........:::_ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY I DATE RECEIVED <br /> 0 r1 $............................... € <br /> .v .... ............... <br /> .................................................................................. <br /> ........................................................................................... <br /> EH 23 032 (REVISED 1-12-98) <br />