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SAN JOAQUIN COUP OUBLIC HEALTH SERVICES - ENVIRONMEATAL REAL' `IVSIOM ' UND X111 STORAGE TANK PROGRAM - FEE uORXSHEEt S FACILITY SITE NAME 1986 ` 1987 ( 1988 ' 1989 � 1990 I FA ITY CONTACT NAME I S 7 - car ,- T 'E FACILITY ADDRESS XXXX I XXXX I =cc ` xXXX S XXXXXXXX SITE PHONE + with AREA CODE c XXXX ' xXXX )0= I �� ts� n• ,h (�- C�- I V iANK r'E° = 550.00/TANK (Prior to January 1,1941) I 6`, 93--3--3,//& a CITY TE Td ZIP CCDE : of TANKS A ' 1996 11997 1998 ac SITE I xxxx XXXX I I I ! I S P P APPLICANT/BILLING NAME 1 APP CANT CONTACT NAME L C-- r'l-6-o C� II TANK PENALTY FEES ASSESSO xm ` )C= I xXXX I XXXX IXXXX >7 I C MAILING ADDRESS S L II STATE SURCHARGE FOR 4Ei1 FACILITIES ONLY -$18.:0 APPLICANT PHONE 4 WITH AREA CODE S T Y 11 ranks x 58.00 I 1988 through 1993 (S56) N T CITY SURCHARGE FCR 1998 STATE ZIP CODE I TYPE of APPLICATION S (Closure, Instal (ac, on, etc.)RIC 14 .— r TOTAL C' PERMANENT CLOSURE (Removal or AuthoriZed Closure -in -Place) I TANK I.O. (s) L, 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) ( + TANK(s)X 5234.00 = S S UI 7E*1PCRARY CLOSURE (P(an .Review 3 Inspections) TANK I.J. :(s) Ej TEMPORARY CLOSURE FEE = 578.013/hour (3 hours minimum/FACILITY) ` 5734.00 minimun � S �,I INSTALLATION ?LAN CHECK (Plan ,Review 3 Construction Inspections)I TANK I.O. .(s) L� A NI PLAN CHECK FEE = S78.00/hour (8 hours minimus/FACiLtTY) = 5624.00 minimus S Rl RE?AIR FEE (Uorkalan Review 3 Constriction Inspections) I 1986 ` 1987 ( 1988 ' 1989 � 1990 TANK LINING REPAIR FEE = 578.00/hour (3 hours minim n/TANK) I ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 S A A I I XXXX I XXXX I XXXX I =cc ` xXXX S XXXXXXXX C T FACILITY PENALTY FEES ASSESSED (If Applicabte) XXXX ' xXXX )0= I )0= I XXXX S XXXXXXXX I V iANK r'E° = 550.00/TANK (Prior to January 1,1941) I 5170/TANK (After January 1, 1941) E = 11988 11989 11990 1991 11992 1993 11994 11995 ' 1996 11997 1998 Flranks (muttipty T oy fee for I xxxx XXXX I I I ! I S Al each year applicable) I xXXX xXXX XXXX C� II TANK PENALTY FEES ASSESSO xm ` )C= I xXXX I XXXX IXXXX I ! S L II STATE SURCHARGE FOR 4Ei1 FACILITIES ONLY -$18.:0 S T Y 11 ranks x 58.00 I 1988 through 1993 (S56) 1993 through 1997 (S56)i T998 SURCHARGE FCR 1998 I XXXXXXXXXXXXXXXXXXXXXXXXXXX xxxxXXXXXXXXXXXX)()=XXX S C' PERMANENT CLOSURE (Removal or AuthoriZed Closure -in -Place) I TANK I.O. (s) L, 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) ( + TANK(s)X 5234.00 = S S UI 7E*1PCRARY CLOSURE (P(an .Review 3 Inspections) TANK I.J. :(s) Ej TEMPORARY CLOSURE FEE = 578.013/hour (3 hours minimum/FACILITY) ` 5734.00 minimun � S �,I INSTALLATION ?LAN CHECK (Plan ,Review 3 Construction Inspections)I TANK I.O. .(s) L� A NI PLAN CHECK FEE = S78.00/hour (8 hours minimus/FACiLtTY) = 5624.00 minimus S Rl RE?AIR FEE (Uorkalan Review 3 Constriction Inspections) I TANK I.J. *(s) E, PI TANK LINING REPAIR FEE = 578.00/hour (3 hours minim n/TANK) I $ TANK(s) X 5234.00 = S A I TANK RETROFIT REPAIR FE_ = S78.00/hour (3 hours min./FACILITY) = SZ34.013 minimum i S R PIPING .REPAIR FEE = 578-00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S MI TRANSFER FEE = 520.00 I I UNAUTHCRIZJ RELEASE EVALUATION = S73.00/hr ' I S S' C CONSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION FEE = S78.00/hr I S TOTAL DUE _ FOR OFFICE USE ONLY SuE=PS^may COMPUTER $ I LOC CODE I OIST CODE AMOUNT RECEIVED I CHECX */CASH RECEIVED 3Y � GATE TEC=-IVEO I S EH 23 032 (REVISED 1-12-98)