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4 SAN JOAQUIN Aj1VTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL A&TH DiVSION RGROUND STORAGE TANK PROGRAM - FEE WORKSHAW SI FACIL T T NAME FACILITY CONTAY11110 E rr EI FACILI ARE S I SITE PHONE # with AREA CODE 161rd. &r7 i 1987 i 1988 AI 11990 &E' ZIP CO � j � of TANKS at SITE P P! APP DANT/ ILQ N r i A +ANT CeTACT N L� I I e C! MA MNG ADDRESS A! i APPLICANT PHONE T WITH AREA E N, XXXX I XXXX XXXX TC 'Y � STATE;,4lP CODE TYPE or APPLICATION (Closure, Installation, etc-) C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) ( TANK 1.D. 9(s) l' - 01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) ( TANK(s) X 5234.00 = S S' UI TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. '-(s) R' - E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) ( S234.00 minimum P; INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)! TANK I.D_ »(s) L' A! NI PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S S RREPAIR FEE (Workplan Review & Construction Inspections) i I TANK I.D. T(s) E PI TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) i 9 TANK(s) X S234.00 = 5 A' I; TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum g S RI 6 IPIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S MI TRANSFER FEE = S20.00 I I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr l i 5 I sI I i C CONSULTATION FEE = S78.00/hr I ( SAMPLING INSPECTION FEE = S78.00/hr I I S TOTAL DUE S FOR OFFICE USE ONLY - • = = == _ moi€ = .€_ _i SUEEPS �I COMPUTER R i LOC CODE I DIST CODE I AMOUNT RECEIVED 1 CHECK #/CASH �I RECEIVED 3Y I DATE RECEIVED EH 23 032 (REVISED 5-27-97) TOTAL 1986 i 1987 i 1988 1989 11990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 Al C I XXXX I XXXX XXXX I XXXX XXXX S XXXXXXXX R A T =AGILITY PENALTY FEES ASSESSED (If Applicable) I j XXXX j XXXX j XXXX j XXXX ! XXXX S XXXXXXXX V' TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January i, 1991) E �' Tanks = 1987 j 1988 1989 11990 1 1991 1992 1993 1994 1995 1996 1 1997 F(multiply by fee for A each year appticabie) XXXX XXXX ; XXXX XXXX ;XXXX i 5 C: I! TANK PENALTY FEES ASSESSED XXXX I XXXX XXXX XXXX XXXX 11I j S L' Ii STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 �S T' Y! R Tanks x S8.00 1988 through 1990 (S56) 1991 througn 1996 CS56) 1997 k qG SURCHARGE FOR 1997 XXXXXXXX XXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX yi S C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) ( TANK 1.D. 9(s) l' - 01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) ( TANK(s) X 5234.00 = S S' UI TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. '-(s) R' - E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) ( S234.00 minimum P; INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)! TANK I.D_ »(s) L' A! NI PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S S RREPAIR FEE (Workplan Review & Construction Inspections) i I TANK I.D. T(s) E PI TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) i 9 TANK(s) X S234.00 = 5 A' I; TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum g S RI 6 IPIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S MI TRANSFER FEE = S20.00 I I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr l i 5 I sI I i C CONSULTATION FEE = S78.00/hr I ( SAMPLING INSPECTION FEE = S78.00/hr I I S TOTAL DUE S FOR OFFICE USE ONLY - • = = == _ moi€ = .€_ _i SUEEPS �I COMPUTER R i LOC CODE I DIST CODE I AMOUNT RECEIVED 1 CHECK #/CASH �I RECEIVED 3Y I DATE RECEIVED EH 23 032 (REVISED 5-27-97)