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SAN JOAQUIN COUF'jj1kPU8LIC HEALTH SERVICES - ENVIRONMENTAL HEAD IVSION <br /> UNDWOUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> "E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 0' , [r <br /> AP-46 0 -=';7- - <br /> CITY STATE ZIP CODE # of TANKS <br /> Aat SITE <br /> P <br /> S!�Mevnyj 1<94. <br /> PLICANT BILLING NAME APPLICANT COCT NAME <br /> L <br /> I <br /> C MAJ.LING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX I I $ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY= d If $ <br /> T <br /> Y # Tanks x 48.00 1988 through 1993 (S56) 1993 through 1997 ($56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> N+ TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr I ( S <br /> I 4 l I ! <br /> St <br /> C CONSULTATION FEE _ $78.00/hr I SAMPLING INSPECTION FEE _ $78.00/hr I $ <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> _::::::::::::•-::--:::::::_—:_•-::::-:::::::::::::::::-::::::::::.—::::::.:............_.._................................. <br /> SWEEPS # ! COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> �s <br /> _ �. <br /> EH 23 032 (REVISED 1-12-98) <br />