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SAN JOAQUIN ����.'Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL h H DIVSICN <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHE0090, <br /> S FACILITY SITE NAMEFACILITY CONT�y NAME <br /> E FACILITY ADDRESS SITE <br /> & Z PHONE # with AREA CODE <br /> d PHit /S r <br /> I <br /> CITYT STATE ZIP CSE _ atoSITE KS <br /> A 1 Qom- ^va\ 957 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CON CT NAME <br /> dlc ' n r wu �Sc�✓` <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A S 6 1 r c <br /> M <br /> T CITY �S E ZIP CODE TYP APPLICATION <br /> D/� <br /> orac)o ( LTL7� asur Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A %XXX %XXX %XXX %XXX %XXX S XXXXXXX% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I %XXX XXX% %XXX %XXX xxxx S %XXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1987 1988 1989 1990 1991 1992 1993 1994 1995 19% 1997 <br /> F (multiply # by fee for <br /> A each year applicable) %XXX %XXX I Xxxx Xxxx XXxx S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXx Xxxx %XXX I xXxx IXXXX I I I I I I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = 518.50 i5 <br /> T <br /> Y # Tanks x $8.00 1988 through 1990 (S56) 1991 through 1996 (556) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXxxxxxxxxxxxxxxxX xxxxxxxxxxxxxxxxxxxxxxx S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)1 X 5234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = E78.00/hour (3 hours minimmm/FACILITY) 5234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.001hour (B hours minimm/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) % 5234.00 = E <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 = 578.001hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> 5 <br /> l I <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE 115E ONLY <br /> a SWEEPS # COMPUTER # LOC CODE I DIST CODE I AMOUNT RECEIVED CHECK #/CASH RECEIVED BY OATS RECEIVED <br /> S mama <br /> EH 23 032 (REVISED 5-27-97) <br />