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• SAN JOAQUIN COUNf%*IBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTI,VSION <br /> UNDERGROIAID STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME 'In <br /> � FACILITY CONTACT NAME <br /> 1 ' <br /> T e S w' TK <br /> "E FACILITY ADDRESS SITE P NE # with AREA CODE <br /> p � �� � S 4) 0 2 - 137 0 <br /> A CITY %OCK 1 0(V STATE ZJ,P5-2 # of TANKS <br /> (( at SITE <br /> P I <br /> P APPLICANT/BILLING NAME F PPLICANT CONNTTACL 6ME <br /> L N(e.D O \ 1t0(1 I ( Gel)Qr <br /> I <br /> C 14AILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> M <br /> 005 5e �Ufl `( to - - l on <br /> T CITY - 1 STATE ZIP CODE TYPE of APPLICATION <br /> ST �/ �0 CI) 2�5 (Cl�r�, Instal lai9an, etc.7 �)p�1� <br /> h TOTAL <br /> 7986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 1100.00 <br /> A %XXX xxxx xxxx xxxx xxxx I S xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X%XX XXXX XXXX xxxx xxxx f xxX%%%xX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1988 7989 1990 1991 11992 1993 1994 1995 11996 11997 1998 <br /> F (multiply F-67-fee for <br /> A each year applicable) xxxx xxxx I %XXX xxxx xxxx f <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX I XXX% I xxxx XXXX Ixxxx I II S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T 1 Y # Tanks x 58.00 7988 through 1993 (156) 1993 through 7997 (156) 7998 <br /> SURCHARGE FOR 1998 xxxx%xxxxxxxxxxxxxxxxxxxxxx XXXXXXXXXXXXXXXXXXXXX%% S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R m <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minim/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s) _ X $234.00 I S <br /> A <br /> I - TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minimum S <br /> mTRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I S <br /> � � 1 <br /> S I I <br /> ClCONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE 578.00/hr s <br /> TOTAL DUE 5 WZ <br /> FOR OFFICE USE ONLY - <br /> _..._�. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> =w Ji M12 (RFV1SF.D 1-12.98) <br />