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SAN JOAQUIN COLIC HEALTH SERVICES - ENVIRONMENTAL HEA *ION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET F0 0� 799,E <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I ,/y/An� C i/. PE <br /> T <br /> 'E FACILITY ADDRESS SJ,TE PHONE k with AREA CODE <br /> (ZoR� �7�—3ZoK� <br /> c <br /> CITY 1 STATE ZIP CODE 9 of TANKS <br /> P �6 at SITE Z <br /> P APPLICANT/BILLING NAME #Z.IPCO.DE <br /> ANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS ANT PHONE it WITH AREA LODE <br /> A <br /> N TYPE of APPLICATION <br /> T CITY <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 1 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XX%X XXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) %XXX %XXX %XXX XXXX %%XX 5 XX%%XXXX <br /> f <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (Atter January 1, 7991) �j(J •(j51 71p$ <br /> E <br /> k Tanks = � 1988 7989 1990 1991 1992 1993 1994 7995 11996 11997 7998 <br /> F (multiply # by fee for <br /> A each year applicable) X%XX XXXX %XXX XXXX XXXX 3'dp zy�p •je�p I3�/� 3`Ip 52,bt/O•ov <br /> C <br /> I TANK PENALTY FEES ASSESSED %XXX XXX% xxxx XXXX XXX% I�� i c7 3`'f� I fit' 3�0 �p fZ�rj a�p• <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 5 /S•SV <br /> T <br /> Y Al Tanks x Se.00 1988 through 1993 (556) 1993 through 1997 (556) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXX%XXX%XXXXXXXXX%XXX XXXXX%XXXXXX%XXXXX%XXXX (� TS /=6 <br /> (�, bU <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.O. a(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minim VTANK) It TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (PLan Review S Inspections) TANK I.0- *(a) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimiMFACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. ,Y(a) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimus/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) A TANK(s) X 5234.00 = I S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 mini mm S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S IClCONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE $ i ,r <br /> FOR OFFICE USE ONLY <br /> ..,�n—::vm:m_ <br /> SWEEPS N COMPUTER At LOC CODE DIST CODE AMOUNT RECEIVED CHECK X/CASH RECEIVED aY DATE RECEIVED <br /> e - <br /> i <br /> S <br /> max. . <br /> :irr,.....,_.......__..__..........._... ...... ....._._..._......_._.............__...__..._........._..... _._._.._.._._..._...-........._.___......,m: _--_::__:::��>_ —rt.r_ _,_—_..-T__:�:;a:M:..:-�_...., <br /> :W Ji n4J (RFVISFD 1-12-98) <br />