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10 ` SAN JOAQUIN Cagd&UBLIC HEALTH SERVICES - ENVIRONMENTAL HE�IVSION <br /> U OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T SITE PHONE # with AREA CODE <br /> "E FACILITY ADDRESS 'q <br /> & o . v <br /> CIT� o-,� STATE ZIP CODE # of TANKS <br /> p So? O at SITE <br /> P u•� APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> H STATE 21P CODE TYPE of APPLICATION <br /> T CITY (Closure, Installation, etc.) <br /> TOTAL <br /> qa9 9d' �-�c_• G fi- <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 XX%x %Xxx XXX% %XXX XXX% S X%xxxxxx <br /> A <br /> CXxxx XXXx XXXX xx%x XXxx S xxxxxxxX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I5170/TANK (After January 1, 1991) <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E <br /> # Tanks = ,_ 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 199 <br /> F (multiply # by fee for 5 <br /> A each year applicable) xx%% %%xX X%%x xxx% XXXX <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXX% %xxx X%XX XxxX "Inq*D O <br /> L $ fid'•`✓v <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br /> T1998 <br /> Y # Tanks- x $8.00 1988 through 1993 ($56) 1993 through 1997 (556) <br /> SURCHARGE FOR 1998X%xxx xXxxxxxxxXX%xxxxxxxx%%% $ <br /> X%%X%%XXXXXXXX%XX%XXXX <br /> EPERMANENT LOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> # TANK(s)__ X $234.00 = $ <br /> = 578.00/hour (3 hours minimum/TANK) TANK I.D. #(5) <br /> LOSURE (Plan Review & Inspections) 5 <br /> LOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> 5 <br /> N[P---N------F- <br /> A <br /> LACHECK EE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <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) X 5234.00 = <br /> A S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> R 5 <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> I <br /> SS <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br /> TOTAL DUE $ a(o .60 <br /> ONLY _ ........_.__.__ .......___..._.........___:::_.::_::__—::-::::-::.-:::--::: -::::::::::::::.—_:_.-::::::_::::::::::::::::_-.:::::::-:i::�............:.......... <br /> FOR OFFICE USE .:... <br /> aaaa <br /> Dis <br /> ::::::::::::::::::::::::::::::::..::.::::::::::::::::::::..::::::::::..:.::::::::::::::::::::::..:::::�::: .::............ .. ...::i':=it[:tiii i�iiiii`.t:._a;,:':i:='siii�'i'siiiiiiT!iaiii;i iii::i::iiiiii iiiiiiiiiiiii�..;..s.:.�:::::::::�:::::: <br /> diiiiiiiii_iiiiiiiiiiiiiiiii_i::iii:iii;;aiiiiii_:i€i.i::iiiiiiiiiiiiiiiiiii iii5_aiiii:._ i:::::;:i::: ........._...:.. ... ATE RE <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY <br /> is <br /> Sits; __ <br /> d: ...._._ ..................... . ....... ........ as <br /> .................... <br /> aagn <br /> as. <br /> EH 23 032 (REVISED 1-12-98) <br />