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SAN JOAQUIN CQMV PUBLIC HEALTH SERVICES - ENVIRONMENTAL H i DIYSION ROUND STORAGE TANK PROGRAM - FEE WORKSN S I FACILITY SITE NAM�E S %?'/t� FACILITY CONTACT NAME 1986 6)on i+ l< �7b ,icNEr : 7� r:,� J!'p� . !' fS A ✓ T E FACILITY ADDRES,S,� ( SITE PHONE # with AREA CODE ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 0 -//`f Z & A CITY // {) L-c;'ce L STATE ��9�Gcf ZIP CODE # of TANKS at SITE XXXX I XXXX X)= S X)=XXXX U P P APPLICANT/BILLING NAME APPLICANT CONTACT NAME /��.�✓� �.k S �%,ti/tom. s TUB: ,/L� I E C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE T �� S'7yS' .Sid 7 -� tJSdL N T CITY�/ e`,Y,,0 )J 7� STATE I C -q ZIP CODE ,t5 J % 1 TYPE of APPLICATION a (Closure, Installation, etc.) TOTAL CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) 1986 1987 1988 11989 1990 A ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = 5 XXXX XXXX XXXX I XXXX X)= S X)=XXXX U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) S a �! C E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S X)O=XXX I V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) E 4 Tanks = 1987 1 1988 1989 1990 1991 1992 1993 1 1994 1995 11996 1997 F A (multiply # by fee for each year applicable) XXXX XXXX XXXX XXXX Inn I I I I 5 C I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX IXXXX I I I I S L I STATE SURCHARGE T Y # Tanks x 58.00 1988 through 1990 (S56) 1991 through 1996 (S56) 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S SURCHARGE FOR 1997 CPERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) E L P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = A N 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = 5 I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minimum S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) S a �! R E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. #(s) E L P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = A N PLAN CHECK FEE = 378.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S R REPAIR FEE (Workplan Review & Construction Inspections) i TANK I.D. As) 'l i,..,l. 44, E P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S A I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minimum S R PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S a �! M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I Cl CONSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION FEE = 578.00/hr FOR OFFICE USE ONLY SWEEPS # COMPUTER # I LOC CODE I DIST CODE ' AMOUNT RECEIVED I CHECK it/CASH S EH 23 032 (REVISED 5-27-97) S S TOTAL DUE S . Z y C-t— RECEIVED BY I DATE RECEIVED 1,4 C