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SAN JOAOUIN COX PUBLIC HEALTH SERVICES - ENVIRONMENTAL NEA )IVSION <br />UND'w"(XjN) STORAGE TANK PROGRAM - FEE WORKSHEET *WO' <br />S <br />FACILITY S TE NAME <br />FACILITY CONTACT NAME <br />I <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) = S624.00 minimum <br />T <br />0 <br />E <br />FACIL HY ADDRESS SITE PHON # with AREA CODE <br />a <br />a09 — 9 4q — 95 - <br />A <br />CITY STATE ZIP CODE # of TANKS <br />9s at SITE / <br />11988 11989 <br />7 <br />P <br />U <br />P <br />AP ICANj/BILLING AME <br />APPLICANT CONT CT NAME <br />S <br />.00 <br />I <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimm/FACILITY) <br />X%XX <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />XXXX <br />5 <br />633 <br />N <br />C <br />T <br />CIT STATE ZIP CODE TYPE of APPLICATION <br />S2 (Closure, Installation, etc.u) <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) = S624.00 minimum <br />TOTAL <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />S <br />S <br />1986 <br />1987 <br />11988 11989 <br />1990 <br />U <br />ANNUAL FACILITY FEE (Prior <br />to January 1, 1991) = $100.00 <br />R <br />S <br />.00 <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimm/FACILITY) <br />X%XX <br />XXX% <br />I XXXX I <br />%XX% <br />XXXX <br />S XXXXXXXX <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXX% <br />XX%X <br />I XXXX <br />X%XX <br />XX%X <br />S xxxxxxx% <br />I <br />V <br />TANK FEE = S50.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK <br />(After <br />January <br />1, <br />1991) <br />E <br />9 Tanks = _ <br />11987 1988 1 1989 1 1990 <br />11991 <br />11992 <br />1993 <br />11994 <br />1995 11996 <br />1997 <br />F <br />(multiply # by fee for <br />I <br />I <br />S <br />A <br />each year applicable)XXXX I XXXX I XxXX I X1(XX (XXXX <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />%X%X XXXX I X%XX ( %XXX <br />X%XX <br />1 <br />1 <br />1 <br />I I <br />1 <br />S <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 <br />05 <br />T <br />Y <br /># Tanks_ x 58.00 <br />1988 through 1990 <br />(556) <br />1991 through 1996 (556) <br />1997 <br />SURCHARGE FOR 1997 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXxxxxxXXXXXXxxxxxx <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) = S624.00 minimum <br />S <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review 8 Inspections) <br />TANK I.O. #(s) <br />R <br />S <br />.00 <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimm/FACILITY) <br />$234.00 minimum <br />S <br />P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) <br />TANK I.D. #(s) i <br />L <br />E <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) = S624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review 8 Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />S <br />A <br />I <br />R <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum <br />S <br />.00 <br />PIP ING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimus <br />s <br />TRANSFER FEE = S20.00 <br />I <br />S <br />Ci CONSULTATION FEE = S78.00/hr <br />ONLY <br />COMPUTER # 1 LOC CODE <br />ER 23 032 (REVISED 5-27-97) <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = 878.00/hr <br />