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SAN JOAQUIN CMAHLY PUBLIC HEALTH SERVICES - ENVIRONMENTAL SEMI DIVSION <br /> �WRCUND STORAGE TANK PROGRAM - FEE WORKSH <br /> SI FACILITY SITE NAME FACILITY CONTACT NAME <br /> 11 ' 5'� f <br /> T <br /> EI FACILITY ADDRESS SITE PHONE with AREA CODE <br /> &i 3 a-OA091 `ls7' - .2900 <br /> 1 CITY ATATEI ZIP CODE of TANKS <br /> Al ` ( ��'�0 dj I at SITE <br /> P, <br /> PI APPLICANT BILLING NAME APPL CART CONTACT E <br /> LI <br /> 1, <br /> C, MAILING ADDRESS /1 I APPLICANT PHONE " WITH AREA CODE <br /> A' S3 S A}./111 6 311 <br /> Tj CITY STATEI ZIP CODE i TYPE of APPLICATION <br /> 9Sz p S (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 , 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 1 <br /> AII XXXX ' XXXX XXXX I XXXX XXXX 3 S XXXXXXXX <br /> C' 7I <br /> Tj FACILITY PENALTY FEES ASSESSED (if ADplicable) j XXXX XXXX XXXX + XXXX 1 XXXX S XXXXXXXX <br /> I <br /> VI TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> F' <br /> Tanks = 1987 1988 ( 1989 1 1990 i 1991 1992 ; 1993 i 1994 1995 1996 11997 <br /> Ff Cmultiply # ..y fee for <br /> Al each year app['cable) XXXX I XXXX XXXX I XXXX 1xxxx j 4 I S <br /> C' <br /> I', TANK PENALTY FccS ASSESSED , XXXX XXXX I XXXX I XXXX 1xxxx i S <br /> L <br /> I! STATE SURCHARGE FOR NEW FFACILITIES ONLY = S18.50 i5 <br /> T' <br /> Y; A Tanks x 58.00 1988 through 1990 (556) I 1991 through 1996 (S56)� 1997 <br /> SURCHARGE FOR 1997 I XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C! PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. A(s) <br /> L; y <br /> 01 CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) i I TANK(s) X 5234.00 = 3 <br /> S; <br /> UI TEMPCRARY CLOSURE (Plan Review & Inspections) TANK I.D. A(s) <br /> Rj <br /> Ei TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> i <br /> P1 INSTALLATION PLAN CHECK (Plan Review b Construction inspections)! TANK I.D. A(s) s <br /> L, <br /> AI <br /> NI PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) ( TANK I.D. A(s) <br /> PI TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I A TANK(s) X 5234.00 = S <br /> A{ it9 <br /> I1 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = SZ34.00 minimum 1 S <br /> R ! <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 3234.00 minimum S <br /> MI TRANSFER FEE = S20.00 I ( UNAUTHORIZED RELEASE EVALUATION = S78.00/hr i S <br /> II <br /> S ! <br /> i <br /> C; CONSULTATION FEE = S78.00/hr ! SAMPLING INSPECTION FEE = S78.00/hr i I S <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> -—---.. .........__...._;.-.. <br /> SWEEPS #_ I COMPUTER A I LOC CODE i DIST CODE I AMOUNT RECEIVED ( CHECK A/CASH I RECEIVED 3Y I _ DATE RECEIVED <br /> I y <br /> - A <br /> EH 23 032 (REVISED 5-27-97) <br />