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SAN JOAQUIN ' TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL I TH DIVSION <br /> l%./_RGRCUNU STORAGE TANK PROGRAM - FEE WO(IKSHEL,.,, <br /> S FACILITY SITE NAME FACILITY CONTACT RNAME <br /> I J tSL S <br /> T <br /> E FACILITY ADDRESS SITE PH011E # With AREA CODE <br /> i <br /> CITY STATE ZIP CODE # of TANKS <br /> A a at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L 5 <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A _ <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 7986 1987 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $700.00 <br /> A XXXX XXXX XXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) )XXX XXXX XXXX XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> At Tanks 1987 1988 1989 1990 1991 1992 11993 1994 1995 11996 1997 tiA4 <br /> F (multiply ##cy fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX )000( I S <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX I XXXX I XXXX XXXX )XXX I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 it <br /> T <br /> Y # Tanks z 88.00 1988 through 7990 (S56) 1991 through 1996 (S56) 1997 ,q <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXX%XXXX%XXXXXXXXXXXX 5 <br /> CPERMANENT CLOSURE (Removal or Authori Zed Closure-in-PLace) I TANK I.D. #(s) <br /> L <br /> D CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 S ?� w <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) �--� <br /> R <br /> E TEMPORARY CLOSURE FEE - S78.00/hour (3 hours minimm/FACILITY) 5234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (PLan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A d <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimum 5 /] <br /> Rj REPAIR FEE (Workplan Review 3 Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> x <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimm/FACILITY) $234.00 minimum S <br /> Mj TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr f I S <br /> 1 1 <br /> Cl CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE - S78.00/hr S <br /> TOTAL DUE S [ 3 6 0= <br /> FOR OFFICE USE ONLY <br /> __—._..._ .: _. .:. .....:...... ..... .....:: .. .�:::�. .. ....[::[iii[::=�: �:::::s::: <br /> wN <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK */CASH I RECEIVED BY DATE RECEIVED <br /> 5 <br /> EH 23 032 (REVISED 5-27-97) <br />