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4 <br /> ^ SAN JOAQUIN CC* PUBLIC HEALTH SERVICES - ENVIRONMENTAL HA DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACE TY CONTACT NAME <br /> T <br /> 'E FACILITY ADDRESS SITE PHONED with AREAA CODE <br /> 8 <br /> CITY STATE ZIP CODE of TANKS <br /> A �: I ,-�i -:.� at SITE <br /> P <br /> P APPLICANT/, ILLING NAME APPLICANT CONTACT NAME d <br /> CIILING DRESS APPLICANT PHONE WITH AREA CODE <br /> N z,, <br /> T CITY STATEI ZIP CODE TYPE of APPLICATION <br /> y ' "' .(Ctosure, InstaLLation, etc.) <br /> t 4^1 �� � �n <br /> . ,zo l J <br /> TOTAL <br /> 1986 1987 11988 1 1989 1990 <br /> ANNUAL FACIL17Y FEE (Prior to Januar 1, 1991) = 3100.00 <br /> A y XXXX I x%Xx XXXX X%XX I XX%% S XXXXXXXX <br /> C' <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %%X% I xx%x I XXXX I XX%% I XXXX S XX%XX%XX <br /> 1 { <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) 1 <br /> 1 <br /> E ; Tanks = 1988 11989 1990 1991 ! 1992 11993 1994 11995 11996 1997 11998 <br /> FI (multiply by fee for <br /> AI each year acpLicable) XXXX XXXX x%X% %XXX IxX%x S <br /> C 3 <br /> II TANK PENALTY FEES ASSESSED I %%%X I X%XX I XXXX ' XXX% :%%X% � <br /> L, I <br /> 11 STATE SURCHARGE FCR NEW FACILITIES CHLY=318.50 { 3 <br /> T1 <br /> T� Tanks_ x $8.00 1988 throucn 1993 (356> 1993 :h rough 1997 ($5d) 1998 I <br /> SURCHARGE FOR 1998 xxxxxxxx%%%XXXXXX%xxxxxxxxx XXXXX%%%XXXX%X%XXX%%%%X s <br /> Cl PERMANENT CLOSURE (Removal or Authorized Ctosure-in-PLace) j TANK I.J. :(s) <br /> L ( 4 TANK(5) X $234.00 = S <br /> OCLOSURE FEE = 578.00/hour 3 hours minimum/TANK) j <br /> Si. <br /> Ul TEMPORARY CLOSURE (PLan Review 3 Inspections) TANK 1.D. (s) <br /> I <br /> R <br /> El TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 3234.00 minimum 1 3 <br /> PI INSTALLATION PLAN CHECK (Plan Review 3 Construction !nscections)l TANK I.D. d(s) 1 <br /> LI 1 <br /> AlNPLAN CHECK FEE = 378.00/hour (8 hours minimum/FACILITY) = 3624.00 minimum S <br /> Rl REPAIR FEE ('Workplan Review 3 Construction Inscections) j TANK I.J. ;(s) <br /> E, <br /> PI TANK LINING REPAIR FEE = 378.00/hour (3 hours minim. /TANK) = TANK(s) X $234.00 = 13 <br /> A. <br /> 11 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234,00 minimum S <br /> R, Z a <br /> PIPING REPAIR FEE = 378.00/hour (3 hours minimum/FACILITY) = $234,00 minimum S <br /> i <br /> i l <br /> M TRANSFER FEE = $20.00 I i UNAUT40RIZED RELEASEE EVALUATION = 578.00/hr I I S <br /> I <br /> S <br /> C CONSULTATION F.. = S78.00/hr I SAMPLING INSPECTION F?= = 578.00/hr 1 S <br /> TOTAL DUE S O L e 6) <br /> FOR OFFICE USE ONLY !' <br /> :;:''=e:-::::::::iiiio-eie;eeeeee:eeeii::;:.e-_::::::: _";=;e-:=::ie-::e[ii:::e:eii-:ee::eeea::e:eee:::_::':- <br /> .:........_............... ................................__................._..._ ...__........_...._._.......... _....._ <br /> SWEEPS CCMPUT_3 j LOC CODE DIST CODE I AMOUNT RECE!VEJ CHECK d/CASH RECEiVE7 SY TATE RECEIVED <br /> i <br /> - <br />