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SAN JOAOUIN CUM PUBLIC HEALTH SERVICES - ENVIRONMENTALH DIVSION <br /> ' UNWOUND STORAGE TANK PROGRAM - FEE WORKSHEV <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I S r_ vz,oR <br /> 'E FACILITY ADDRESS TE PHONE # with AREA CODE <br /> ��L U ��?, - -j <br /> CITY STATE ZIP CODE # of TANKS <br /> A — at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L E:_ <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N ��5� �v ' ` z �� 5 <br /> T CITY STATE ZIP CODE TYPE of APP <br /> C �U �SN - ? (Closure, Installation, etc.) � j <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX I XXXX XXXX XXXX $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) —7 V op <br /> E <br /> 9 Tanks = 1988 1989 1990 1991 1992 1993 11994 1995 1996 1997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX <br /> C <br /> ITANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T <br /> Y # Tanks T x 58.00 1988 through 1993 ($56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S l� <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S p�� <br /> S uu <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum LS <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = S234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr I I <br /> Es <br /> S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE 5 ' 4/� Op <br /> : <br /> FOR OFFICE USE ONLY <br /> _.............._............. ............................_...... _ _ .__..._ - .:«•...--:::.M...........�, _.._.._•._..�= = ...-., .... .:: -_.... ...___. __.......:..;::::::: <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED I CHECK */CASH <br /> j RECEIVED BY DATE RECEIVED <br /> S <br /> ............._.• ............._........_.__....._...._z ..... ___ •-:—.-_..-m.« _.v ::::>r:s::a• s: <br /> ...............:::r.:....«.._. .......__..._..._.._.._.«::::.-::=..:.::�•:^•_�..�.`.»�....._.__.__._......__.;. ... ....._.. ..__......... <br /> EH 23 032 (REVISED 1-12-98) . • <br />