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SAN JOAQUIN COLI. ?UBLIC HEALTH SERVICES - ENVIRONMENTAL HEALWIDIVSION <br /> UNDERLROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T �sr hI , w i <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> Z UA 7C <br /> CITY STATE ZIP CODE # of TANKS <br /> A <br /> P C.A 57L1 at SITE <br /> s <br /> P APPLI aI CLING NAME /' APPLICANT CONTACT NAME <br /> M �G ADD�Fc�S A�PP��!{T PHONE # WITH AREA CODE <br /> U G� X33 <br /> -T LIT p STATE ZIP CODE TYPE of APPLICATION <br /> T c�C1-p. e' 7 (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 _ <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A xxxx xxxx %X%% XXX% xxxx S XXxxxxxX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx xxxx I xxxx %XXX $ XXXXXXXx <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = - 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 <br /> F (multiply #by fee for <br /> A each year applicable) XXXX XXX% xxxx xxXx XXXX 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED I xxxx xxxx xxxx XXXX XXXX I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br /> T <br /> Y # Tanks_ x 58.00 1988 through 1993 ($56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxx XXXXXXxxxxxxxxxxxxxxxxX 5 ' <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) I # TANK(s) X 5234.00 = S <br /> S —_ <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 5 <br /> ------------------ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br /> S � ' <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> 4 <br /> R G g <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACIL•ITY) = $234.00 minimum <br /> 5 <br /> N TRANSFER FEE = S20:00UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> I g <br /> S <br /> C CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = 578.00/hr <br /> S <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> REE <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK f!/CASH I � RECEIVED BY DATE RECEIVED <br /> ......_....._....-__._........:_�:::�____:::_:_:__:::::� <br />