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r <br />o s SAN JOACAJIN CgM PUBLIC HEALTH SERVICES - EVVIRCNMENTAL HEALTH DIVSION <br />OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />Si FACILITY SITE NAME <br />T1r <br />El FACILITY ADDRESS <br />FCITY <br />A �'7`✓G <br />P <br />P APPLICANT/BILLING NAME <br />L <br />C MAILING ADDRESS <br />A <br />N 1 <br />TI CITY <br />�� t SG dCk%fid d FACILITY CONTACT NAME <br />6— <br />SITE <br />SITE PHONE {�.+i th AREA CODE <br />A7 Z <br />SEI ZIP CODE ` of TANKS <br />IC e S 5 I at SITE �? <br />d <br />APPLICANT CONTACT NAME <br />STAT'c ZIP CODE <br />/V-5 )/v <br />CANT PHONE + WITH AREA CODE <br />LICATION <br />(CLosure Rmtallation, etc.) <br />TOTAL <br />OFFICE USE ONLY <br />SWEEPS :9 -COMPUTER LOC CODE <br />EH 23 032 (REVISED 1-12-98) <br />DIST CODE`I AMOUNT RECEIVED I CHECK +/CASH I RECEIVED 3Y II DATE RECEIVED <br />�S L <br />1986 <br />ANNUAL FACILITY FEE (Prior to January t, 1491) = 5100.00 I XXXX <br />11487 � 5488 11989 11990 <br />A <br />XXXX I XXXX XXXX I XXXX <br />5 XXXXXXXX <br />CI <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX I XXXX I XXXX I XXXX <br />5 XXXXXXXX <br />I <br />V <br />TANK FEE = 550.00/TANK (prior Co January 1,1991) I ;170/TANK (After January 1, 1991) <br />i <br />E <br />F <br />A <br />Tanks = 1 <br />(multiply by fee for <br />each year applicable) <br />I <br />1988 11989 11990 l 1991 11992 11993 11994 ( 1995 11996 11997 1998 <br />XXXX XXXX I XXXX XXXX lXXXX <br />( I I I I I I <br />S <br />Ci <br />I <br />TANK PENALTY FEES ASSESSED I XXXX ` XXXX I XXXX I XXXX XXXX I I ` <br />S _ <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br />S <br />T <br />Y <br />lk <br />T Tanks x 58.00 <br />SURCHARGE FOR 1998 <br />1988 through 1993 (556) <br />1493 through 1997 (556)# 1998 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX S <br />C� PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) I TANK (.0. T(S) <br />L, <br />01 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I TANK(s) X 5234.00 - <br />S <br />Uj <br />TEMPORARY CLOSURE ( IPlan Review & Inspections) TANK E.O. $(S) <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) ` ;234.00 minimum <br />P� <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. l(s) <br />L <br />A; <br />N <br />PLAN CHECK FEE = 378.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />R) <br />REPAIR FEE (Workplan Review & Construction Inspections) TANK E.G. $(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 378.00/hour (3 hours minimum/TANK) I TANK(s) X 5234.00 = <br />3 <br />A; <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br />Mi TRANSFER FEE = 520.00 ` I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I 1 S- <br />it i I <br />S. <br />C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr I ; <br />"-CT6 <br />OFFICE USE ONLY <br />SWEEPS :9 -COMPUTER LOC CODE <br />EH 23 032 (REVISED 1-12-98) <br />DIST CODE`I AMOUNT RECEIVED I CHECK +/CASH I RECEIVED 3Y II DATE RECEIVED <br />�S L <br />