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R <br />SAN JOAQUIN AOMBLIC HEALTH SERVICES - ENVIRONMENTAL HEAIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />L <br />T <br />'E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />INIAL <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br />S <br />S <br />S <br />1986 11987 <br />U <br />, t988 � <br />1989 <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />5234.00 minimum S <br />at SITE <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />XXXX <br />XXXX <br />N <br />T) <br />CITY <br />STATE <br />ZIP CODE TYPE of APPLICATION <br />l XXXX <br />xxxx <br />XXXX <br />(Closure, Installation, etc.) <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure - in -Place) <br />TANK I.D. #(s) <br />I <br />L <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />` # TANK(s) X 5234.00 = S <br />INIAL <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br />S <br />S <br />S <br />1986 11987 <br />U <br />, t988 � <br />1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) = 5100.00 <br />5234.00 minimum S <br />A <br />XXXX I <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />S xxxxxxxx <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />l XXXX <br />xxxx <br />XXXX <br />XXXX <br />XXXX <br />S XXXXXXXx <br />I <br />V <br />TANK FEE = 550.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK <br />(After <br />January <br />11 1991) <br />E <br /># Tanks = <br />1988 <br />1989 <br />1990 <br />1991 <br />' 1992 <br />1993 <br />1994 <br />1995 <br />11996 ' <br />1997 <br />1998 <br />F <br />(multiply # by fee for <br />S <br />A <br />each year applicable) <br />XXXX <br />XXXX <br />I XXXX <br />XXXX <br />(XXXX <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />, xxxx <br />xxxx <br />xxxx <br />XXXX <br />j <br />jxxxx I <br />I <br />l <br />S <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br />5 <br />T <br />Y <br /># Tanks x $8.00 <br />1988 through 1993 <br />(S56) <br />1993 through <br />1997 (556) <br />1998 <br />xxxxxxxXXxxxxxxxxxxxxxx <br />5 <br />SURCHARGE FOR 1998 XXXXXXXXXXXXXXXxxxxxxxXXXXX <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure - in -Place) <br />TANK I.D. #(s) <br />I <br />L <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />` # TANK(s) X 5234.00 = S <br />S <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br />S <br />S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(S)— <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum S <br />P <br />INSTALLATION PLAN CHECK (Plan Review $ Construction Inspections)I TANK I.D. #(s) <br />S <br />I <br />L <br />S <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />S <br />M <br />TRANSFER FEE = $20.00 ` UNAUTHORIZED RELEASE EVALUATION = 578.00/hr ( <br />S <br />I <br />S <br />C <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br />S <br />TOTAL DUE <br />S <br />FOR OFFICE USE ONLY <br />SWEEPS # I COMPUTER # LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK 0/CASH RECEIVED BY I DATE RECEIVED <br />cu n niP eRFvisFD 1-12-98) <br />S <br />