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i <br /> SAN JOAOUIN A PUBLIC HEALTH SERVICES - ENVIRONMENTAL He DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACY CONTACT NAME <br /> T SITE PHONE " with AREA CODE <br /> 'E FACILITY ADDRESSPjJC�p - 7 <br /> a <br /> CITY �51AIE ZIP CODE of TANKS <br /> l .� ? I at SITE <br /> A <br /> P.. APPLICANT CONTACT NAME <br /> P APPLICANT ILLING NAME <br /> -roc k <br /> I APPLICANT PHONE T WITH AREA CODE <br /> AI MAILING��DRESS <br /> STATE ZIP CGDE TYPE of APPLI GALLON <br /> T ,tITY e � � CA �I!"�"�/ (C!osure, :ns:allation, etc.) <br /> TOTAL <br /> 1986 11987 1988 1 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.D0 X%XXI XX%X %XXX 1 X%XX I %%XX 5 XX%XXXX% <br /> A <br /> C <br /> T (If Applicable) XXXX XXXX XX%X i XXXX XXX% S XXXX%XXX <br /> IFACT LILY PENALTY FEES ASSESS`cD <br /> 1y 1 8170/TANK (After January 1, 1991) 1 <br /> Y TANK FEE = 550.70/TANK (Prior to Januar ,1991) <br /> E <br /> Tanks = 1988 1 1989 1990 1991 1992 1993 1 1994 1995 j 1996 j 1997 1998 <br /> F (multioty by fee for i <br /> AI each year acplicable) XXxX I XXXX XXX% xxxx !XXXX j 15 <br /> C: 11 j 1 S <br /> II TANK PENALTY FEES ASSESSED 11 XXXX 1 X%XX I XXX% xX%X Xx%X <br /> L, 3 <br /> II STATE SURCHARGE FOR NEW FACILITIES ONLYriS18.50 <br /> T 1993 through 1997 (556) 1998 <br /> YiTanks_ x 38.00 I 1988 to rough 1993 (556) <br /> SURCHARGE FOR 1998 j XX%%%XXXX%%%XXXXXX%XXXXXXXX X%%XXX%X%XXXX%X%%XXX%%X 5 <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) I LANK I.D. (s) <br /> 01 <br /> S234.00 = i <br /> CLOSURE "E` 878 00/hour �3 hours minimum/TANK) � X <br /> TANK(s)_ <br /> S. TANK 1.D. +(5) <br /> Ul TEMPORARY CLOSURE (Plan Review S Inspections) i <br /> R i <br /> Ei TEMPORARY CLOSURE FEE = 378.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br /> PI INSTALLATION PLAN CHECK (PLan Review 3 Construction :nscecticns)I TANK I.D. d(S) I <br /> L <br /> A 5624.00 mi nimun S <br /> NI PLAN CHECK "`- = 578 00/hour (8 hours minimum/FACILITY) _ <br /> Rj REPAIR FEE (Workplan Review 3 Construction Inspections' I TANK I.D. :(s) <br /> E' TANK(s) X 9234.00 = I S <br /> PI TANK LINING RE'AIR --O = $78.00/hour (3 hours minimum/TANK) <br /> AS I <br /> 11 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum {j <br /> R' __ = 5234.00 minimum 1 5 _,7 <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br /> j Mj TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASEEVALUATLGN = 378.00/hr <br /> 5 <br /> II <br /> SS <br /> C CONSULTATION F== = 578.00/hr SAMPLING INSPECTION F=_ = 578.00/hr i <br /> TOTAL DUE S 'LZ OCA <br /> Cc USE ONLY ......_.._'__-__...._............._::::::::::::::--:.-::,:::::::::.-_::__":::.-.--_.-:::::_._.-:_-::::.ttt <br /> _—_ M.:-::: :::::::: <br /> FOR OFFICE ...............___._... .__..._.:.,.:::-:::::-:::::::::.......................___............::::_. - <br /> . ::::: ::ttt[r::t:::tt:ttii:'_i':€€iiiiiii €iiiii- .':':€€€iiDii_,:€N€i=i_i'sii:::::::::; : t='::�t:t:tt[ts[stt:_::1:;:;::::_:::::::::::::::,::::::::::-::-:::::::::::::::_.:::-_::::::-_:-_::-:::::::::,::: :::::::-::: :__;::,: --: :::::::::::::t: <br /> SWEEPS I CGMPUTER d j LOC OCDE DIST CODE AMO(1NT RECEIVED , CHECK :/CASN I RECEIVED SY DATE RECEIVED <br /> o <br />