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SAN JOAQUIN91RGROUND Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION STORAGE TANK PROGRAM - FEE WORKSHEE S FACILITYSITE N ME FACILITY CONTACT NAME I r T CLOSURE FEE = $78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 = $ TOTAL TANK LINING REPAIR FEE = $78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 = $ E FACILITY ADDRESS SITE PHONE # with AREA CODE & 1987 1988 1989 1990 _ $234.00 minim $ d® ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 CITY STATE ZIP CODE # of TANKS A(n^ Q5 (� at SITE P XXXX XXXX $ XXXXXXXX A C P APPLICANT/BILLING NAME AAPPLI NT CONTACT NAME L I MAILING ADDRESS C APPLICANT PHONE # WITH AREA CODE N �1 0 — I — 6 337 T CITY STATE ZIP CODE TYPE of APPLICATION &� 7s-aa®S-- (Closure, Installation, etc.) C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s) L 0 CLOSURE FEE = $78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 = $ TOTAL TANK LINING REPAIR FEE = $78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 = $ A 1986 1987 1988 1989 1990 _ $234.00 minim $ d® ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minim/FACILITY) $234.00 minim $ XXXX XXXXI XXXX XXXX XXXX $ XXXXXXXX A C T FACILITY PENALTY FEES ASSESSED (If Applicable) ( XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX I V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # Tanks = 1987 1988 1989 1990 11991 1992 1993 1994 11995 1996 1997 F (multiply # by fee for XXXX XXXX XXXX XXXX $ A each year applicable)XXXX C I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX I $ L I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 is T Y # Tanks x $8.00 1988 through 1990 ($56) 1991 through 1996 ($56) 1997 SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s) L 0 CLOSURE FEE = $78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 = $ S TANK LINING REPAIR FEE = $78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 = $ A U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minim $ d® E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minim/FACILITY) $234.00 minim $ LI INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) NJ PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minium $ R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E PI TANK LINING REPAIR FEE = $78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 = $ A I R TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minim $ d® PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ MTRANSFER FEE _ $20.00 I -- S -- — — CONSULTATION FEE = $78.00/hr FOR OFFICE USE ONLY UNAUTHORIZED RELEASE EVALUATION = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ $ i EH 23 032 (REVISED 5-27-97)