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SAN JOIIOUIN 'D(TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL, OLT" DIVSION <br /> `OERGROUND STORAGE TANK PROGRAM - FEE WORKSHEft <br /> ET <br /> S FACILITY SITE �NAME <br /> Ttail �— FACILITY CONTACT NAME <br /> 'E FACILITY ADDRESS C. <br /> & Z R�,�L SITE PHONE # with AREA CODE <br /> CITY <br /> V � STATE ZIP CODE # of TANKS <br /> �A 5"' J at SITE , <br /> P APPLI ILLING NAME <br /> APPLICANT CONTACT NAME <br /> I Tat a <br /> C Dc ADD <br /> /�a5 v g <br /> A ,. APPLICANT PHONE # WITH AREA CODE <br /> T CITY �42q <br /> _ <br /> STATE ZIP CSE TYPE of APPLICATION <br /> 3 T c�C�a. Csy �' (Closure, Installation, etc.) <br /> TOTAL <br /> A ANNUAL FACILITY FEE (Prior to January t, 1991) = $100.00 1986 1987 1988 1989 1990 <br /> C XxXX XXXX xxxx xxxx XX%x 5 X%XXXxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I xxxx xxxx xxxx I xxxx xxxx 5 xxxxxxxx <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E 5170/TANK (After January 1, 1991) <br /> # Tanks = 1988 1989 1990 1991 1992 1993 7994 11995 1996 1997 1998 <br /> F (multiply #byby fee for <br /> A each year applicable) XXXX xxxx xxxx %XxX %XXX <br /> C E <br /> I TANK PENALTY FEES ASSESSED I %XXX Xxxx XXXX XXXX XXXX I I I 5 <br /> L <br /> I STATE SURCHARGE FOR NEN FACILITIES ONLY=518.50 <br /> T <br /> Y # Tanks- x 58.00 <br /> 1988 through 1993 (556) 1993 Through 1997 (556) 1998 / <br /> SURCHARGE FOR 7998Xx%XxxxxxxxxXXXXXX%XX%X <br /> E <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(S) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> 5 # TANK(s) % $234.00 = 5 <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234-00 minimus <br /> 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) = 5624.00 minimum ::: <br /> S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimus/TANK) # TANK(s) % 5234.00 = g <br /> A <br /> I TANK RETROFIT REPAIR FEE 578.00/hour (3 hours min./FACILITY) = 8234.00 minimum <br /> R g <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = $234.00 minimus <br /> E <br /> M TRANSFER FEE = 520:00UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> I g <br /> S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr <br /> S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY .. <br /> = SWEEPS # I COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/CASH I RECEIVEDBYLI DATE RECEIVEDi u <br /> EN 23 032 (REVISED 1-12-98) <br />