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SAN JOAQUIN C 7 PUBLIC HEALTH SERVICES - ENVIRONMENTAL W 4 DIVSION <br /> l'w--,dlGROUND STORAGE TANK PROGRAM - FEE WORKSHEE,, <br /> S FACILITY SITE NAME FACILITY CONTArT NAME <br /> T %GG y�S G4E' ir c Ie- — <br /> "E FACILITY ADDRESS SSPHONE # with AREA CODE <br /> A pp c L�� ( r/i✓� a -0 335/- 61 <br /> CITY STATE ZIP CODE # of TANKS <br /> A lj0(7( G/y;C0> at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A /rav Gv0/ /avF'. <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Insta(Lation, etc.) <br /> TOTAL <br /> 1986 11987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A I xxxx I %XXX xxxx I xxxx I xxxx S xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX xxxx xxx% %xx% XXXX S %%%XXXX% <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = —"'ll <br /> 1988 1989 1990 1991 1992 11993 1994 11995 1996 1997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXX% XXXX xxxx I /7p /70 �r7J i7o i7G /7o S jozo <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx XXXX XXX% X%xX %XXX 7o/ 11,7 op It 70 /70 1,1 v 17G S j6gJ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T <br /> Y # Tanks x 58.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 %%XXXX%xXx%xxxxxxxXxxxxxxxx xxxxxxxXXXxxxxxxxxxxXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK L.O. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)_ X SZ34.00 = S <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(S) <br /> R <br /> E� TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 mini mum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> l <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimsm/FACILITY) _ $624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 8234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min-/FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> 5 <br /> C CONSULTATION FEE = E78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> :.--:_:_- _. - .. t.:: .:..- ::.__:_:::::__.:::_::_:::::_:-:.—.—_::::::::::_,:,-:-::::::-;--.--:_:_.—__.........._:::_::.__.....:_..._...—..................._.._._.........._...........__._. <br /> SWEEPS # COMPUTER At LOC CODE DIST CODE AMOUNT RECEIVED I CHECK #/GSH RECEIVED BY DATE RECEIVED <br /> II - <br /> _. <br /> . ___ ___ __ —____ _-__— ___ _ <br /> EH 23 032 (REVISED 1-12-98) <br />