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SAN JOAQUIN gWITY PUBLIC HEALTH SERVICES - ENVIROMWAL ff&TH DIVSION <br />GROUND STORAGE TANK PR - FEE WORKSHEW <br />S FAC-ILI•TY SITE NAME FACILITY CONTACT NAME <br />1 Ss#°1-6(7/ <br />T <br />PERMANENT CLOSURE (Removal'or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />E FACILITY ADDRESS <br />L <br />A <br />N <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) <br />SITE PHONE # with AREA CODE <br />& 6 <br />TOTAL <br />[ <br /># TANK(s) L' X $234.00 = v <br />5 70 <br />CITY <br />2-3 <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />1989 <br />1990 <br />U <br />at SITE <br />P <br />$234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />= $234.00 minim <br />P APPLICANT/BILLING NAME <br />$ <br />R <br />APPLICANT CONTACT NAME <br />L I- <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minim/FACILITY) <br />$234.00 minim <br />S <br />I <br />C MAILING ADDR SSZ <br />XXXX <br />XXXX <br />APPLICANT ONE # WITH EA CODE <br />A J 7 <br />XXXX <br />$ XXXXXXXX <br />N <br />S <br />C <br />CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE <br />= $78.00/hr <br />$ <br />T CITY <br />Ste+ <br />P C� <br />TYPE of APPLICATION <br />�- �fK h1A <br />°7V <br />/7 G! <br />1 <br />(Closure, Installation, etc.) <br />C <br />PERMANENT CLOSURE (Removal'or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) <br />= 5624.00 minim <br />L <br />0 <br />TOTAL <br />[ <br /># TANK(s) L' X $234.00 = v <br />5 70 <br />2-3 <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />$234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />= $234.00 minim <br />R <br />$ <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minim/FACILITY) <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minim/FACILITY) <br />$234.00 minim <br />S <br />A <br />M <br />XXXX <br />XXXX <br />)XXX <br />XXXX <br />XXXX <br />$ XXXXXXXX <br />S <br />C <br />CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE <br />= $78.00/hr <br />$ <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />)XXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />S XXXXXXXX <br />I <br />V <br />TANK FEE _ $50.00/TANK <br />(Prior to January 1,1991) <br />$170/TANK <br />(After <br />January 1, 1991) <br />E <br /># Tanks = <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 1993 <br />1994 <br />1995 <br />1996 <br />1997 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />I <br />$ <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = 518.50 <br />�$ <br />T <br />Y <br /># Tanks x 58.00 <br />1988 through 1990 <br />(S56) <br />1991 through 1996 (S56) 1997 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />SURCHARGE FOR 1997 <br />C <br />PERMANENT CLOSURE (Removal'or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) <br />= 5624.00 minim <br />L <br />0 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK)+ <br />[ <br /># TANK(s) L' X $234.00 = v <br />5 70 <br />2-3 <br />R <br />S <br />TANK I.D. #(s) <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />$234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />= $234.00 minim <br />R <br />$ <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minim/FACILITY) <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minim/FACILITY) <br />$234.00 minim <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) <br />= 5624.00 minim <br />��`� <br />5 �a6 <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minim/TANK) <br /># TANK(s) X <br />$234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />= $234.00 minim <br />$ <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minim/FACILITY) <br />_ $234.00 minim <br />$ <br />M <br />TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />$ <br />I <br />S <br />C <br />CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE <br />= $78.00/hr <br />$ <br />FOR OFFICE USE ONLY <br />ff <br />SWEEPS COMPUTER ! COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH <br />$ <br />EH 23 032 (REVISED 5-27-97) <br />TOTAL DUE I S / b _5 <br />RECEIVED BY DATE RECEIVED <br />