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• 4: <br /> • SAN JOAQUIN Ct PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION <br /> ` UNDe GROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAM <br /> I <br /> T .J <br /> E FACILITY DRESS - SITE PHONE # with AREA CODE <br /> & 4/`l K) Q.(f2 A09 - - i <br /> CITY <br /> A STATE ZIP CODE # of TANKS <br /> l/IcsL <br /> P at SITE <br /> P APPLICANT/ ILLING NAME APPLICANT CONTACT NAME <br /> LLl <br /> //�� � <br /> I _L&9,f/LL.( ifa�.r1-� <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A 538 k� Am 9 - (� 33 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION Yc��-�"+-+L-C,�� <br /> �et • 9sa 0 S (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A %XXX %XXX I X%XX XX%% XXX% S X%%XX%xX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX %XXX %%XX %X%K XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 19913 <br /> E <br /> # Tanks = 1987 1988 1 1989 1990 11991 1992 1993 1994 11995 1996 1997 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX I XXX% I Xxx% XXXX I I $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXX% I XXXX I XxxX XXXX S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 b5 <br /> T <br /> Y # Tanks_ x $8.00 1988 through 1990 (856) 1991 through 1996 (S56) 1997 <br /> SURCHARGE FOR 1997 XXXXxxxxxxxxxxxXXXXXXXxxxxx XXXXXXXXXXXXXXXXXXXXXxx 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 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(a) <br /> — <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minioun S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) X 8234.00 = S <br /> A <br /> IR TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S 00 <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I 5 <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr g <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY ..:.....t OATE�RECE[VED <br /> iii.._....__..._......_._._.........__........._... <br /> S <br /> M MM <br /> MMM: MUMNUM: <br /> EH 23 032 (REVISED 5-27-97) <br />