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• SAN JOAQUIN a3xTT IC HEALTH SERVICES - ENVIRONMENTAL HEALTH 07'5104 <br /> . UMOERGila.d STORAGE TANK PROGRAM - FEE110AnHEFT <br /> FACILITY CCHTACT NAME <br /> Sl FACL L[TY SITE NAME ♦ 1111 <br /> T PHONE + with AREA CCAS <br /> "E FACILITY ADDRESS <br /> L TATE{ ZIPI a of TANKS1 <br /> CITY I 6 as SITE <br /> A <br /> P I APPLICANT wHTAC NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I I APPLICANT PRONE 0 WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N $TATEI ZIP CGDE I TYPE of APPLICATION 1 <br /> Tj CITY (CLasure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 11988 7989 11990 <br /> FEFEE (Prior to January 1, 1991) = 5100.00 I X%Yx XXxx -zm )0= I xxxx S xx=xxx <br /> I XXXX I XXXX XXxxx I xxxx xxxx S XXXXXXXX <br /> FEES ASSESSED (It Applicable) I <br /> Si7D/TANK (After January 11 1991) <br /> 0/TANK (Prior to January 1,1991) <br /> 1988 1989 11990 1991 11992 1993 1994 1995 119961997 1998I <br /> F (multiply = by fee for 1 S <br /> A each year applicable) —)ax I XXXX I XXXX I %XXX �%%%% I I I I I I S <br /> C[ ------------ <br /> TANK PENALTY FEES ASSESSED I xxxx I LC(X I xxx% ` XXxx Ixxxx I I I I I I S I <br /> L <br /> ( $TATE SURCHARGE FOR NEA FACILITIES ONL7=518.50 l <br /> T 1988 through 1993 (S56) 1993 through 1997 (SSfi)� 1998 <br /> Y 9 s Tankx 58.00 ' I S <br /> SURCHARGE FOR 1998 <br /> XXXXXxxxx%x«XXXXXxxxXxxXxX XXXXx)O=XXXXXXXXX%XXXX <br /> TANK I.O. 41(s)--- <br /> CI PERMANENT CLOSURE (Removal or Authorized Clasure-in-Plac') - 5 <br /> L I : TAHK(5)— X 5234.00 <br /> OICLOSURE FEE = 578.00/hour (3 hours mini—TANK) <br /> $II TANK 1.0. 3(s) <br /> U TF <br /> _4PORAR7 CLOSURE (Plan Review S Inspecti oral 5 I <br /> R = 55.00/haw (3 hours minimm/FACILITY) I 5734.00 minimum <br /> E TEMPORARY CLOSURE FEE <br /> PI INSTALLATION PLAN CHECK (Plan Review L Construction [nspr_tiare)I TANK 1.0. :(s) <br /> L I s <br /> A = 5624.00 minimum <br /> N ?LAN CNECK FEE = 578.00/hour (a hours minimm/FACILITY) <br /> IRl REPAIR FEE (Workplan Review L Construction InspectTara) TANK 1.0. 0(s) I s <br /> E I d TANX(s) �� X 5234.00 = <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) 15 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.OG mini" 1 5234.00 minimAn S <br /> R = <br /> P[P[NG REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) <br /> Ni TRANSFER FEE = 520.00 I I UNAUTHORIZED RELEASE EVALUATION = S78.OG/hr I I 1 <br /> IS <br /> S I I SAMPLING INSPECTION FEE <br /> C = 578.00/hr <br /> CANSULTATiON FEE = 578.00/hr <br /> TaTu DUE 5 <br /> FOR OFFICE USE ONLY _ — - <br /> SYEE?$ S --I COMPUTER d I LOC CODE I 0[ST CODE AMWNT REC`IVEO I CHECX :/USH I RELIVED By <br /> i GATE dEC[VET - <br /> 3 I I S <br /> EH 23 032 (REVISED 1-12-981 <br />