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SAN JOAOIIN COUIT��,,rr__aL�IC NEALTN SERVICES - ENVIRONMENTAL NEILLT!' SIO1 <br /> LNIDERGI UJFo STORAGE TANK PROGRAM - FEE WORKSHEET ' <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I M.1 Is <br /> T SITE PHONE # vi th AREA CODE <br /> -E FACILITY ADDRESS <br /> m;l RodcJ <br /> b I STATE ZIP CODE a of TANKS <br /> CITY at SITE <br /> A GIL <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L Lar g,�4{o-• <br /> i APPLICANT PHONE # WITH AREA CODE <br /> C NAILING ADDRESS <br /> A Cilli 6lq-4577 <br /> CD• x <br /> YCITY STATE ZIP CODE IIGTION <br /> bacror..c� <br /> Lb Q3864 (Closure, nstaltation, etc.) <br /> TOTAL <br /> �1986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to Ja ary i, 1991) = s100.00 XX XXXX XXXX XXXX XXXX S xxxxxxxx <br /> A <br /> C xxxx xxxx xxxx xxxx xxxx s xxxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> 1 <br /> V TANK FEE = f50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 7998 <br /> F (Dauttiply # by fee for ` S <br /> A each year appticsbte) xxxx xxxx xxxx xxxx nn <br /> Cr jI TANK PENALTY FEES ASSESSED , xxxx XXXX XXXX I Xxx% %XXX I ! I s <br /> L f <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY-1118.50 <br /> T <br /> Y # Tanks_ x 58.00 1988 through 1993 (S56) 1993 through 1907 ($56) 7998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX xxxxxxxxxxxx=XXXXXXXXX 5 <br /> —71 <br /> CI PERMANENT CLOSURE (RemovaL or Authorized Ctosure-in-dace) I TANK I.D. At(S) 74r13702 <br /> L # TANK(s) 2 x 5234.00 S <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimaa/TANK) I ' 1a4• o0 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review b Inspections) TANK I.D. #(s) <br /> R S <br /> E TEMPORARY CLOSURE FEE • 578.00/hour (3 hours minimum/FACILITY) f234.00 minimus <br /> LA ALLATION PLAN CHECK (Plan Review b Construction Inspections)I TANK L0. #(s) <br /> CXECK FEE 578.00/hour (8 hours minSmun/FACILITY) _ %24.00 winiaaat <br /> R REPAIR FEE (Workplan Review b Construction Inspections) I TANK I.D. #(s) <br /> E s <br /> P TANK LINING REPAIR FEE - 578.00/hour (3 hours minimum/TANX) I # TANK(s) �_ x �-0 <br /> AS <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 Sown min./FACILITY) (234.00 minimum <br /> R5 <br /> PIPING REPAIR FEE = (78.00/hour (3 hours minimMFAC1LITY) = (234.00 minimum <br /> MI TRANSFER FEE a 520.00 UNAUTHORIZED RELEASE EVALUATION - 571.00/hr I S <br /> I <br /> S = 1178.00/hr I f <br /> CI CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br /> TOTAL pw S <br /> FOR OFFICE USE ONLY L.�...�, ,�, ss- •-3= _,---��-' .�..mom . ..:. - -e -. "" <br /> .x• w'rt� a - nw� tea'' <br /> �CLv�-,'..� '6�m�5...3:Wu�.:.- ciMOUNT RECEI,m��.vT+P$EC33ult CASH S-T-ED 3Y.=�a�n..�c.n <br /> SWEEPS At COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK */CASH RECEIVED dT GATE RECEIVED <br /> .eep.t��,� <br /> ::ourca,:::•isa�.�`�-r,._,�;�..,a- <br />