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SAN JOAQUIN TftTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL 10WH DIVSION <br />GROUND STORAGE TANK PROGRAM - FEE WORKSH <br />.ITY SITE NAME <br />FACILITY CONTACT NAME <br />�- <br />.ITY ADDRESS <br />f CC) t l X27. <br />SITE PHONE # with AREA CODE <br />A <br />zoo - 9 3 (-9,7"G./o <br />1986 1987 <br />1988 <br />CA To 4 c <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />CA- <br />g52 -(j <br />atoSITENKS <br />ra ice"" v rzr,1�? <br />!CANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />C.1,( 7 P -A (-F-(C .C-iaiY, <br />Se- (C7 <br />[NG ADDRESS <br />--r+f <br />APPLICANT PHONE # WITH AREA CODE <br />a-'iK <br />�S 1-- 9 0 (- ? 3 qH <br />TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />E <br />F <br />A <br />C <br />C4 <br />% <br />osur , Installation, etc.) <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) <br />TOTAL <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />1986 1987 <br />1988 <br />1989 1990 <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />XXXX XXXX I XXXX <br />XXXX XX $ <br />XXXXXXXX <br />C <br />T <br />1 <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />$ <br />XXXX XXXX <br />( XXXX <br />XXXX XXXX $ <br />XXXXXXXX <br />V <br />TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br />$170/TANK (After <br />January 1, 1991) <br />E <br />F <br />A <br />C <br /># Tanks = <br />(multiply # by fee for <br />each year applicable) <br />1987 1988 <br />1989 1990 1991 <br />1992 <br />1993 1994 <br />' 1995 <br />1996 1997 <br />XXXX XXXX <br />XXXX XXXX XXXX <br />I $ <br />I <br />L <br />TANK PENALTY FEES ASSESSED <br />XXXX XXXX <br />XXXX XXXX XXXX <br />$ <br />I <br />T <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 <br />1$ <br />Y <br /># Tanks x $8.00 <br />SURCHARGE FOR 1997 <br />1988 through 1990 ($56) <br />1991 through 1996 ($56) 1997 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX <br />$ <br />j <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />S <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s)—j—_ X <br />$234.00 = $ <br />��-- <br />U <br />R <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) <br />_ $624.00 minimum <br />$ <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />P <br />A <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />I <br />R <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum <br />$ <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimLan <br />$ <br />M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br />I <br />S <br />C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br />TOTAL DUE I s <br />FOR OFFICE USE ONLY <br />EN 23 032 (REVISED 5-27-97) 0 9 <br />