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SAN JOAQUIN CCJ"" PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH OIVSION <br /> UN. 10UNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILI Y SIT N ME arL FACILITY CONTACT NAME <br /> T <br /> E FACILITI ADDRES _ SITE PHONE ' with AREA CODE <br /> a 3 G7ily (a 0"(5 q& 4/'' Q �a� s <br /> CITY — G� STATE C7P CODE ;tSITEAl / <br /> P /L/47 <br /> Pi APPLICAN/J/8[LL1NG NAME APPLICANT CONTACT NAME <br /> L V <br /> 1. <br /> Cl MAILING ADDRESS - APPLICANT PHONE # WITH AREA CODE <br /> AI �iL(�(/1� QJ <br /> x <br /> Tj CITY L { STATE ZIP CODE TYPE of APPL I CAT I ON 6 ft(;K rJYQj.�1� <br /> G 1'LQyL •�} �.5 L� (Closure, Inst Llat i,pn, etc.) 'yL <br /> TOTAL <br /> 1986 1987 11988 1989 7990 <br /> I ANNUAL FACILITY FEE (Prior to January 1, 1991) = 3100.00 <br /> Al I %XXX %XXX %XXX I XXXX XXXX i %XXX%%XX <br /> C' <br /> Tj FACILITY PENALTY FEES ASSESSED (If Applicable) ( XXXX XXXX %XXX XXXX I XX%X <br /> I <br /> VI TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E; <br /> i # Tanks 1988 1989 11990 1 1991 ( 1992 1993 11994 11995 1996 11997 1 y� <br /> FI (multiply # by fee for y _ d <br /> A� each year app(icable) XXXX XXXX <br /> I XXXX XXXX .XXX% K1 f S �ea� l' <br /> C' <br /> 11 TANK PENALTY FEES ASSESSED I XXXX XXXX I XXXX XXXX XXXX )0QlT <br /> I �Ii-lCr! ' I10- 116- o0jo Sl oaQ ' <br /> L, _ <br /> II STATE SURCHARGE FOR NEW FACILITIES ONLY--MtB:70- 100-0 <br /> S Q <br /> T' <br /> Y1 # Tanks x S8.00 1988 through 1993 (S56) 1993 chrougn 1997 (S56) yg <br /> SURCHARGE FOR 1998 I XXXXXXXXXXXXXXXXXXX%XXX%XXX XXXXXX%XXXX%XXX%XXXXXXX 3 S <br /> C; PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) i TANK I.D. #(s) <br /> L, <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(S)_ X 5234-00 = S .3 y�i1' <br /> S' <br /> UI TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.D. +'(s) <br /> R. <br /> S <br /> Ei TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br /> P, INSTALLATION PLAN CHECK (Plan Review iL Construction Inspections)! TANK I.O. #(s) <br /> L, <br /> AI <br /> NI PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) 5624.00 minimum S <br /> Rl REPAIR FEE (Workplan Review 3 Construction Inspections) TANK I.D. #(s) <br /> E. <br /> PI TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(S) X 3234.00 = S <br /> A' <br /> LI TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.O0/hour (3 hours minimm/FACILITY) = S234-00 minimum S <br /> MI TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr I S <br /> 3, <br /> C1 CONSULTATION FEE = S78.00/hr SAMPLING INSPECT! N AE9 Alffll = 578.00/hr 5 °v <br /> TOTAL DUE S <br /> bar' <br /> FOR OFFICE USE ONLY <br /> - - <br /> w:i :_ <br /> SWEEPS # COMPUTER # i LOC CODE DIST CODE I A T REH'IVSD I CHECK */CASH j RECEIVED 3Y DATE RECEIVED <br /> .:— <br /> L <br /> EH 23 032 (REVISED 1.12-98) /.•Q/(f'?CC'.-/��i. 1-ll I I 1 �� C�/ \����,C1v L yOs'✓FJ <br /> lie a .` llifled �uyC l 5Gor4(% \�Jf O( <br />