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R <br />SAN JOAGUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL HAhH DIVSION <br />STORAM TANK PROGRAM <br />- FEE YORKSH <br />S <br />I <br />FACILITY SITE NAME ®p <br />FACILITY CONTACT NAME <br />T <br />"E <br />FACILITY ADDRESS E�pp eOp <br />80�% �...,oIA�F�t. � E1`� � <br />A <br />SITE PHONE # with AREA C13DE <br />2� — 471 " <br />®�-�p <br />®� i 1 <br />& <br />Ai <br />CITY�we <br />oma <br />STATE <br />ICA <br />ZIP CODE <br />0 59 <br /># of TANKS <br />at SITE <br />R <br />' PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum <br />$ <br />LAPPLICANTkLLING <br />APPLICANT <br />CONTACT TQNAME�� <br />Pk 3-V <br />I <br />AC <br />MAILING AD a�_Vr <br />G / �(U74 <br />A'S <br />-7®1NTE <br />�P (G(OC <br />N <br />Tj <br />CITY <br />II <br />STATE <br />ZIP CODE I <br />TYPE of APPLICATION <br />(Ctosure, Installation, etc.) <br />TOTAL <br />1986 1487 (1988 1989 � 1990 <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br />XXXX XXXX ` XXXX XXXX XXXX <br />S XXXXXXXX <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If App(icable) <br />XXXX XXXX XXXX + XXXX XXXX <br />S XXXXXXXX <br />I <br />V <br />TANK FEE = 350.00/TANK (Prior to January 1,1991) I <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks 1 1988 <br />1989 <br />1990 1991 1992 <br />1993 1 1994 11995 1996 ! 1997 1998 <br />F <br />A <br />(multiply # by fee for I'' <br />each year applicable) ! XXXX <br />XXXX <br />XXXX XXXX (XXXX I <br />i <br />$ <br />C <br />I <br />TANK PENALTY FEES ASSESSED I XXXX <br />XXXX <br />XXXX XXXX `XXXX <br />I I I t I <br />S <br />L' <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY --S18.50 <br />--7 <br />5 to <br />T, <br />Y <br /># Tanks x $8.00 1988 through 1993 ($56) <br />1493 through 1997 (556) 1998 <br />. <br />SURCHARGE FOR 1998XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XX XXXXXXXXXXXXXXXXXXXXX <br />5 'j <br />C� <br />PERMANENT CLOSURE (Removat or Authorized Ctosure-in-Place) <br />TANK I.O. #(s) <br />L <br />0 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.O. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. 0(s) <br />L <br />A <br />Is <br />N. <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) <br />_ $624.00 minimum <br />� <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = $78.00/hour <3 hours minim n/TANK) # TANK(s) X $234.00 = <br />S <br />A <br />II <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 -hours min./FACILITY) _ $234.00 minimum <br />S <br />R <br />' PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum <br />$ <br />M� TRANSFER FEE = S20.00 <br />I <br />S' <br />CONSULTATION FEE = 378.00/hr <br />FOR OFFICE USE ONLY <br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />SAMPLING INSPECTION FEE = $78.00/hr <br />S <br />EH 23 032 (REVISED 1-12-98) <br />