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SAN JOAQUIN COIAITY IC HEALTH SERVICES - ENVIRCUMENTAL HEALTA 9 <br /> ON <br /> WWERGxW STORAGE TANK PROGRAM - FEE WCRKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS I SITE ?HONE T with AREA CCDE <br /> A CI Ty I cRSTATE+ ZIP CSE I at SITE <br /> P� APPLICANT/8ILLiNG NAME APPLICANTC^••NTACT NAME <br /> L c-e Ct ee\ <br /> I <br /> C MAILING ADDRESS APP!Z T ?.BONE '. WITH AREA CSE <br /> N <br /> Ti CITY I STATE ZIP CODE TYPE of APPLICATION <br /> ff �l S (Ctasure, instal Latices, etc.) <br /> TOTAL <br /> 1986 � 1487 � 7988 � 1989 ( 1940 <br /> ANNUAL FACILITY F'c= (Prior ca lanuart 1, 5991) = SIOU-00 <br /> Al <br /> f XXXX ` XXXX y XXXX XXXX XXXX S XX; <br /> c' <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I =cc XXXX XXL I XXXX XXXX 3 XXXXXXXX <br /> I <br /> V TANK F2= = 550.00/TANK (Prior to lanuarf 1,1991) I S170/TANK (After January 1, 5991) <br /> EI 1. <br /> 4 7anKs = 1988 11984 11990 11991 15492 11993 1944 1945 1996 1997 1998 <br /> F) (multiply by fee for S <br /> Al =acn year appticabte) ! XXXX I XXXX I XXXX I XXXX j ( ` <br /> Cl <br /> 1� TANK PENALTY FEES ASSESSEDXXX <br /> � XXXX I XXXX C X � =a IX=a � � � � � � � S <br /> L <br /> II STATE SURCHARGE FOR NEL FACILITIE'a ONLY=S18.50 ; <br /> T <br /> Yi '' Tanks x 38.00 I 5988 ztrougn 1993 C556) 1993 wtrcugn 1997 (356) 1998 <br /> SURCHARGE FOR 1998 f S <br /> C;k ?ERMANE4T CLOSURE (Reseal or Authorized Ctosure-in-Ptace) I TANK I.D. 4(s) <br /> L, 3_ <br /> 01 CLOSURE Fe_ = 378.00/hour (3 hours minimun/TANK) + TANKCs) X 32x4.00 = <br /> S' <br /> UI -;ZMPCRARY CLOSURE (Plan Review 3 Inscec:ions) I TANK I.J. *(s) <br /> a y <br /> E; 7cMPCRARY CLOSURE Fc. = 378.00/hour (3 hairs minimtamlFACILZTY) ` 5234.00 minimum 1 3 <br /> P ,NSTALLATICM PLAN CHECX (Plan Review S Ccmzr,-ctfan (nspec.ions)l TANK I.J. i(s) <br /> L <br /> Al9 PLAN CHECX Fre_ = 378.00/hour (8 hours ainimum/FACILITT) = 5624.00 minimum 5 <br /> Rl RE?AIR F (Lortmian Review b Construction Inscections) i TANK I.J. (s) <br /> Pf 7ANK LINING REPAIR = 578.00/hour (3 hours minimum/TANK) ' TANK(s) X 5234.00 = 5 <br /> A <br /> I TANK RETROFIT RE?AIR F—= = 378.00/hour (3 hairs min./FACILZiY) = 3Z34.00 minimum 3 <br /> R <br /> PIPING REPAIR FC= = S78-00/hoar (3 haus minimxm/FACILZTY) = V34.00 minimum S <br /> Al 7RANSF;3 FE= = SZO.00 � � !WXMDRIZz- RELEASE _'/ALUATION = 373.00/hr ` � , 3 <br /> S' <br /> C; CONSULTATION rc= = 378.00/hr I SAMPLING INSPECTION rz-_ = S78.00/hr <br /> TOTAL DUE 5 <br /> FOR OFFTM USE ONLY <br /> suE=-?S CCMPUTER $ I LOC CCDE DIST CCDE AMOUNT REa!VED I CHECX /CASH REs.cIVED 3Y ' SATE 2E-.:IVEJ <br /> 3 I ' S <br /> EH 23 032 (REVISED 1-12-98) <br />