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SAN JOAQUIN COUP M$LIC HEALTH SERVICES - ENVIRONMENTAL HEAL- IVSION <br /> D <br /> UNoE-mpb STORAGE TANK PROGRAM - FEE WORKSHEET '*0'4 <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T SIT PHONE # with AREA CODE <br /> "E FACILITY ADDRESS .- AO 1 .3 _�/ <br /> i -7,07 �. Yoson de v L 1 I <br /> TE P CODE/ # of TANKS / <br /> A CIT]�� 1C� ,J•�✓3Y at SITE <br /> P �((//(( APPLICANT CONTACT NAME/ <br /> P AP LICANT/BILLING NAME y)07TB5 <br /> L ��CUvi�� e✓/�es LQvnn> <br /> I d..,� APPL CANT PHONE # WITH AREA CODE <br /> MAT AOD SS �ot,b� 7P ✓� 20'/) S23`716-1M / 7 STATE ZIP CODE TYPE of APPLICATION b1fo Z//&-tay <br /> T CITY <br /> (Closure, Installation, <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 9100.00 <br /> A %XXX XXXX X%%X XXXX I XX%% <br /> CX%XX XX%X XXX% XXXX XXX% S XXXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) S17O/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks = 1988 1989 1990 7991 1992 1993 1994 1995 1996 7997 17998 <br /> F (multiPLY # Cry fee for ( S <br /> A each year applicable) XXXX XXXX XXXX X%%X XX%X <br /> C I I $ <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX I X%%% XXXX XX%X <br /> L S <br /> II STATE SURCHARGE FOR NEW FACILITIES ONLY=918.50 <br /> T <br /> T # Tanks_ x 58.00 7988 through 1993 (556) 7993 through 7997 (956) 1998 <br /> SURCHARGE FOR 1998 XXXXXX%%XXXXXXXXXXXXXX%XXX% XX%XXXX%XXXX%%%XXXX%%%% i S <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.D. #(s) <br /> RE! TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = S624.00 minimum S <br /> RI REPAIR FEE (Workplan Review 8 Construction Inspections) TANK 1.0. #(a) <br /> E <br /> P TANK LINING REPAIR FEE = 978.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 9234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 9234.00 minimum 9 <br /> M TRANSFER FEE = SZO.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I ( S <br /> I <br /> S <br /> ClCONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE GIST CODE I AMOUNT RECEIVED CHECK #/CASH RECEIVED BY GATE RECEIVED <br /> S = <br /> EH 23 032 (REVISED 1-12-98) <br />