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SAN JOADUIN COON���UMLIC HEALTH SERVICES - ENVIRONMENTAL HEAC�VSION <br /> UNOERGKOUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 5 FAGFLITY SITE NAME FACILITY CONTACT NAME <br /> I c ks� I'll `F ' uu f )D�fC' <br /> T SIT PHONE 9 with AREA CODE <br /> E FACILITY ADDRESS <br /> ' v -77.`.j 1l/ <br /> 3 7C 7 C/ rvC `G' V <br /> CITY//t f/ 04 STATE L7 P CODE It of TANKS <br /> A illI A41 t'�LC }33�., at SITE <br /> P APPLICANT CONTACT NAME <br /> et U <br /> PP pPQLICANT/BILLING NAME <br /> I L�UYIiJD L'r!}�PS <br /> C MAI ING ADDRESS� APPL CANT PHONE X UI`�TH AREA CODE <br /> A �0 7 C• IGS/lit c Ave /5 `J <br /> STATE ZIP CODE TYPE of APPLICATION �.?SAe &C <br /> Ti CITY J1 <br /> � ^3_;/ (Closure, Instaltation, etc.) <br /> Y y 't- TOTAL <br /> 1986 1987 11988 1989 11990 ' <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 X%%X X%%% %XXX X%%X XXXX S %XXXX%%% <br /> A <br /> CXXX% %XXX %%%% I xX%X x%%% S %XXXX%%% <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I 5170/TANK (After Januar 1, 1991) <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I Y <br /> E <br /> i <br /> X Tanks = 1988 1989 11990 1991 1992 1993 11994 11995 1996 1997 i 1998 <br /> FI (multiply %by fee for 5 <br /> Al each year applicable) %%%% I X%%X %XX% I X%%% I%%%X <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXX %X%X I X%X% I %XXX (XXXX I I I I 5 v <br /> L. t/Q <br /> II STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 I <br /> T. <br /> YIa Tanks_ . 38.00 1988 througn 1993 (356) 1993 tnrough 1997 (S56) '.998 <br /> SURCHARGE FUR 1998 %XXX%%%%XXXX%%X%XX%%%X%X%XX X%XXX%X%X%%%%XXXX%%%X%% ' S <br /> C1 PERMANENT CLOSURE (Removal or Authorized Closure-i n-Place) TANK I.D. #(s) <br /> L' <br /> OI CLOSURE FEE = 378.00/hour (3 hours minimm/TANK) I TANK(s) % 5234.00 = S <br /> S! <br /> UI TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. X(s) <br /> R' <br /> EI TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P! INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. x(s) <br /> LI <br /> A <br /> N1 PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R1 REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. X(s) <br /> E <br /> PI TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) N TANK(s) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE - 578.001hour (3 hours min./FACILITY) = $234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE = 178.00/hour (3 hours minimum/FACILITY) = $234.00 minimum 5 <br /> N1 TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hrI - { S <br /> I <br /> S' <br /> CI CONSULTATION IEE = 578.00/hr I SAHPU NG INSPECTION FEE = 578.00/hr I S <br /> FOR OFFICE USE ONLY ._,.__..._..____....._.......,._z_....._.._. ,.___ TOTAL DUE <br /> .:,_. ... _ 'x <br /> SWEEPS # COMPUTER I LOC CODE DIST CODE AMOUNT RECEIVED I CHECK F/CASH I RECEIVED 0Y I DATEREFry <br /> .....__.._. . . _ .......::. , _ <br /> :: ....._ .....___.:. ...... .......:.: ..:: ._....._ - _...._-- ... <br /> EH 23 032 (REVISED 1-12-98) `� <br />