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SAN JOAOUIN COU! 'UBLIC HEALTH SERVICES - ENVIRONMENTAL HEA" )IVSIDN <br /> UNDE JUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> -E FACILITY ADDRESS SITE PHONE » with AREA CCOE <br /> & hAAm 333-&Boo Ga0 <br /> CITY STATE ZIP CODE�— at SITE <br /> TANKS <br /> SITE <br /> A (> CA a Sz 4 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS A PLICANT PHONE » WITH AREA CODE <br /> A D. 6a�c 3a0 2�oa 3331250D e,�J-• (A U <br /> N <br /> T CITY �STAATE ZIP CODE TYPE of APPLICATION <br /> CA (Closure, Installation, etc.) f-- ?A(P, <br /> TOTAL <br /> 1986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX I XXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX I XXXX XXXX XXXX XXXX S XXXXXXXX <br /> I <br /> V� TANK FEE = S50.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks = 1988 ( 1989 1 1990 1 1991 11992 1 1993 11994 11995 11996 11997 11998 <br /> F (multiply by fee for <br /> A each year applicable) XXXX XXXX I XXXX I XXXX XXXX I I I I S <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX XXXX I XXXX XXXX I I I I , S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T f <br /> Y " Tanks x 58.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 J <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I 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 /> Ul TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.O. »(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. "(s) 1 <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. »(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) » TANK(s) X S234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S 2?) pv <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I <br /> S I I I <br /> C CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = S78.00/hr $ I <br /> TOTAL DUE S 2 115 On <br /> FOR OFFICE USE ONLY – --............ ......... <br /> ..a:::::::::::::::::::::::::,: ::....... ..........:___::_: _ :_ RECEIVED <br /> t <br /> SWEEPS » I COMPUTER » I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK 9/CASH I RECEIVED BY Y I DATE <br /> i <br /> �......._..._._......_............_.....__1.._._. 1.. _ _.. - <br /> EH 23 032 (REVISED 1-12-98) <br />