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SAN JOAOUIN couNr ILIO HEALTH SERVICES - ENVIRONMENTAL HEALTK IEION <br /> UNDER6%Kb 0 STORAGE TANK PROGRAM - FEE WORKSHEET V <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T '.1 I S. Emit o <br /> 'E FACILITY ADDRESS SITE PHONE X with AEA CWE <br /> c 20 ,5 i oO S} e Zo q(,6- 367 <br /> A CITY 70� STATE 2q,52rCODE b atoSITETANKS <br /> v �L <br /> P APPLICANT/BILLI G NAME APPLICANT CONNT^ACT NAME <br /> I <br /> LjqL A, <br /> C MAILING ADORES APPLICANT PHE '� WITH AREA CODE <br /> A <br /> o�5 ON <br /> % 6 2oq- - n b <br /> T CITY STATE ZIP CODETY PLICATION <br /> oC Ta r -J 52p5 osure stallation, etc.) cl,-5,Ae- <br /> TOTAL <br /> 1986 1987 11988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A <br /> xxxx xxxx Xxxx xxxx xxxx S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XX%X %X)(% %X%X %XXX %%%X f XXXX%XXX <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E <br /> Y Tanks = 1988 1989 1 1990 1991 1992 1993 1994 1995 1996 11997 1998 <br /> F (multiply #byby fee for <br /> A each year applicable) xxxxxXXX I xxxx XXXX XXXX I I S <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx I XXXX I XXXX xxxx Ixxxx f I I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 s <br /> T <br /> Y x Tanks_ x 58.00 1988 through 1993 ($56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXxxXxxxxxxxXXXXXXxxxxx XXXXXXXXXXXXXX%XXXXxXXX f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) J TANK I.D. N(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I 0 TANK(s)� X 5234.00 = s flL- <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.O. x(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 mini num S <br /> pINSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. x(a) <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) I TANK I.D. !(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) 0 TANK(5) X 5234.00 = f <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 = E78.00/hour (3 hours minimus/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = E20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I <br /> S I 1 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr I S <br /> TOTAL DUE S 4 S5 <br /> FOR OFFICE USE ONLY <br /> SWEEPS X COMPUTER x LOC CODE DIST CWE AMOUNT RECEIVED I CHECK x/CASH -may—RECEIVED BY DATE RECEIVED <br /> cw YK n27 nRFV1SF.D 1-12-98) `} <br />