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SAN JOAOUIN COONLIC HEALTH SERVICES - ENVIRONMENTAL HEALT*A[ON <br />UNDER OUNO STORAGE TANK FROM M - FEE WORKSHEET <br />FACILITY CONTACT NAME <br />I Si FACILITY SITE NAME <br />I <br />FACILITY ADDRESS <br />CITY <br />P APPLICANT/BILLING NAME <br />L <br />I <br />ClMAILING ADDRESS <br />CITY <br />SITE PHONE % with AREA CODE <br />ZIP CODE S of TANKS <br />at SITE <br />APPLICANT CONTACT NAME <br />APPLICANT PRONE S WITH AREA CODE <br />STATE I ZIP CODE { TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />CI PERMANENT CLOSURE (Removal or Authorized Closure- in -P'. ace) I TANK 1.0. rt(S) <br />L3 TANX(s) X 5234.00 = <br />OI CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) ! <br />S. I TANK I.O. Y(s) <br />U TEMPORARY CLOSURE (Plan Review 3 Inspections) <br />R <br />EI TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum <br />PI, INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspections)! TANK 1.0. x( <br />PLAN CHECK FEE = 378.00/hour (8 hours minimus/FACILITY) =3624.00 minim m <br />R REPAIR FEE (Workplan <br />Review 3 Construction Inspections) i <br />TANK 1.0. X(s) <br />EX <br />P TANK 'LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />11986 <br />11987 ! <br />1988 11989 <br />11990 <br />I TANK RETROFIT <br />R <br />PIPING REPAIR FEE = <br />ANNUAL FACILITY FEE (Prior to <br />January 1, 1991) = S1D0.00 <br />%%%% <br />I %%%% I <br />%XXX I X%XX <br />XXXX <br />i XX%X%%%% <br />C' <br />I %%%X <br />I %%%X <br />I XXXX XX%X <br />I %XXX <br />S %%%XXXX% <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />I <br />January 1,1991) <br />I <br />5170/TANK <br />(After <br />1anw2ry 1, 1991) <br />I <br />V <br />TANK FEE = 550.00/TANK <br />(Prior to <br />E <br />1988 1989 11990 1991 <br />11992 <br />11993 11994 <br />' 1995 <br />11996 ( 1997 <br />11998 <br />% Tanks = <br />3 <br />tyear <br />XXX% %%XX I XXXX %XX) <br />(XXXX <br />I <br />I I <br />A <br />eachtapplicahle)r <br />I <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I X%XX XXXX I %X%X XXXX <br />IXX%X <br />I <br />I <br />I I <br />13 <br />S <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br />T1993 <br />'988 through 1993 <br />(556) <br />I 1993 <br />^.hrough <br />1997 (556)1 <br />1998 <br />1 <br />T <br />d Tanks x 58.00 <br />I <br />- <br />%XXXX%%%%%%%%XXX%)D=XX <br />I <br />S— <br />XX%XXXX%XX%XX%XXXX%XXXXXXXX <br />1 <br />SURCHARGE FOR 1998 <br />I <br />CI PERMANENT CLOSURE (Removal or Authorized Closure- in -P'. ace) I TANK 1.0. rt(S) <br />L3 TANX(s) X 5234.00 = <br />OI CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) ! <br />S. I TANK I.O. Y(s) <br />U TEMPORARY CLOSURE (Plan Review 3 Inspections) <br />R <br />EI TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum <br />PI, INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspections)! TANK 1.0. x( <br />PLAN CHECK FEE = 378.00/hour (8 hours minimus/FACILITY) =3624.00 minim m <br />R REPAIR FEE (Workplan <br />Review 3 Construction Inspections) i <br />TANK 1.0. X(s) <br />EX <br />P TANK 'LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />R TANK(s) $234.00 = <br />A <br />REPAIR <br />FEE = 378 00/hour (3 hours min./FACILITY) <br />= 3234.00 m1^loam <br />I TANK RETROFIT <br />R <br />PIPING REPAIR FEE = <br />minimum/FACILITY) <br />578.00/hour (3 hours mini/FACILITY) <br />= 3234.00 minimum <br />NI TRANSFER FEE = 520.00 <br />I r— <br />S <br />CI CONSULTATION FEE = 578.00lhr <br />FOR OFFICE USE ONLY _ <br />Y�SWEEPS %. I COMPUTER % LOC <br />Fw 71 ^12 IRFVISFD 1-1298) <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />SAMPLING INSPECTION FEE = 578.00/hr <br />DIST <br />AMOUNT RECEIVED <br />5 <br />S <br />5 <br />S <br />5 <br />S <br />5 <br />3 <br />!S <br />TOTAL DUE 1 S <br />BY <br />