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SAN JOAQUIN STY PUBLIC HEALTH SERVICES - ENVIRONMENTAL OR DIVSIOM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T M101 MA-pr <br /> "E FACILITY ADDRESS 5 TE PHO E k with AREA CODE <br /> & W �tw! <br /> CITYSTAT <br /> E 210 ^ X of TANKS <br /> A C/STAT GG((// at SITE <br /> P <br /> PAPPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I t,l �M)M SRU C/ A�Ne-TTS &r UN�'c 1� <br /> C MAILING ADDRESS APPLICANT PHONE N WITH AREA CODE <br /> N -7 20 ( PA�LI PLL /fUE aO9 Z, <br /> T CITY -f-�� STATE ZIP CODE TYPE of APPLICATION <br /> Lq q7A-71 (Closure, Insta(lation, etc.) <br /> TOTAL <br /> 1986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX I XXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX XXXX XXX% %XXX %X%X $ %X%%XXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (Atter January 1, 1991) <br /> E <br /> x Tanks = � 1988 1989 1990 1991 1992 1993 1994 1995 11996 11997 1998 <br /> ff by <br /> F (multiply fee for <br /> A each year applicable) %XXX %XXX XXX% XXX% XXXX S <br /> I TANK PENALTY FEES ASSESSED XXxX I %XXX I xxxx I XXXX (XXXX I I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 $ <br /> T <br /> Y X Tanks x $8.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 %XX%xxxxxxxxxxxxxxxxxxxxxXx XX%%XXXXXxxxxxxxxXXXXXX S <br /> C PERMANENT CLOSURE (Remova( or Authorized Closure-in-Place) I TANK I.D. S(s) 3 0 d — 6 1 44f0c4, <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) a TANK(s) x 5234.00 = S �g <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. x(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) S234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK 1.0. A(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 mini nXan S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. N(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I At TANK(s) _ X 5234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 mini mm S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimm/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I 1 <br /> S <br /> Ci CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> i <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY _ _ -- <br /> ................................_.._........._..............._................_......................................_........._.......-..........,..._..._.........................:_.._T:..-" - <br /> ...... ......�.._.aH. ..i.:. ....... <br /> _[ <br /> SWEEPS x COMPUTER k LOC LODE DIST CODE AMOUNT RECEIVED CHECK */CASH RECEIVED BY DATE—REC£[VED <br /> $ <br /> L- ----- <br /> :::........ .._...... ...._:_. ... ... ............_...........__....._.................._.....__.... .._............._._......._.............._..- -.._._..._.....__......_._.... _ _- _,_..... <br /> Fw 77 n'i7 (RFV)SFD 1-12-98) <br />