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SAN JOAQUIN C T PUBLIC HEALTH SERVICES - ENVIRONMENTAL H. .I DIVSION <br /> r U. GROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S -rACIL T SI NAME ij (i FACILITY C NTACT NAME <br /> I NAME <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & <br /> 7700 - - S3 <br /> CITY STATE ZIP CODE # of TANKS <br /> A S at SITE <br /> P <br /> P APPLICANT/BILLING NAM5 APPLINT CONTACT N E <br /> L ' / <br /> I c <br /> C MAILING ADDRESS I APPLICANT PHONE # WITH AREA CODE <br /> N i o - -- 6 33-7 <br /> T CITY I STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 1 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> Axxxx xxxx j xxxx xxxx xxxx S xxxxxxxx <br /> c <br /> Tj FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX XXXX Xxxx XXXX S XXXXXXXX <br /> VI TANK FEE = 550.00/TANK (Prior to January 1,1991) i 5170/TANK (After January 1, 1991) <br /> E' <br /> Tanks = 1987 1988 11989 1990 1991 1992 1993 1994 1995 1996 i 1997 <br /> F (multiply # by fee for <br /> I <br /> A each year applicable) XXXX XXXX XXXX XXXX (XXXX I 5 <br /> LI TANK PENALTY FEES ASSESSED XXXX XXXX I XXXX ( XXXX XXXX i I i I g <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 its <br /> T <br /> Y; # Tanks x 58.00 1988 through 1990 (S56) 1991 through 1996 (S56)1 1997 <br /> SURCHARGE FOR 1997 I XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXxxxxxxx 5 <br /> Ci PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> 0CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R i <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I $234.00 minimum 5 i <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br /> L, <br /> A <br /> NI PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P1 TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = S <br /> A <br /> IR TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S mo <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr i 5 <br /> I <br /> S I <br /> Ci CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = S78.00/hr I I S <br /> TOTAL DUE $-Z3 4�• co <br /> FOR OFFICE USE ONLY <br /> :::::::::ssaa:::::::¢tt:s:::::_: -_.... ... ___—_ <br /> [=:= s <br /> -:::::tt::t::::::s:::::s: <br /> SWEEPS # I COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/t_CASH I RECEIVED 3Y I DATE RECEIVED <br /> t;t <br /> E4 23 032 (REVISED 5-27-97) <br />