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• SAN JOAOUIN COUNT LIC HEALTH SERVICES - ENVIRONMENTAL HEALTI. SION <br /> UNDERGk-jND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SI FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & I - o — 23 - 33t <br /> CITY NATE ZIP CODE # of TANKS <br /> A9S3 at SITE <br /> P <br /> P APPLICA T/BILLING NAME APPLIC NT CONTACT41� <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT P E # WITH AREA CODE <br /> A <br /> N -29-3!5 I,c, <br /> 209 - �{(�/ - X337 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION , <br /> qS� 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 XXXX XXXX XXXX XXXX XXXX 3 XXXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX i XXXX XXXX XXXX XXXX 3 XXXXXXXX <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> I E i <br /> 9 Tanks = 1987 1988 1989 1990 1991 11992 1993 11994 1995 1996 1997 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX j 3 <br /> I <br /> Ii TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX IXXXX I I $ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 $ <br /> T <br /> YI # Tanks x 58.00 1988 through 1990 (356) 1991 through 1996 ($56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX 5 <br /> i <br /> I <br /> Ci PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L. <br /> 01 CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) # TANK(s) X 3234.00 = S <br /> S, <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> EI TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 <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 3 <br /> 00 <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum 5 <br /> M TRANSFER FEE = 320.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> I <br /> S <br /> Cj CONSULTATION FEE = 378.00/hr SAMPLING INSPECTION FEE = 578.00/hr j 5 <br /> TOTAL DUE S p� <br /> FOR OFFICE USE ONLY <br /> _............_._.............................................._......._._......... <br /> ................................................................... <br /> ..........:_ ::::::::::¢s:::::: _:_.::s:a:W::................:::::::::::;;:::s:a::::-:¢:a::::s:a :;:::::::::s::::::::::::::::::::s::::::;:::::::::::i€ <br /> SWEEPS # I COMPUTER # I LOC CODE DIST CODE AMOUNT RECEIVED I CHECK #/CASH I RECEIVED BY i DATE RECEIVED <br /> 1 <br /> 1:::::: :....._.._.._._...._.....------........1................. ........_................._._.1....... <br /> $ <br /> EH 23 032 (REVISED 5-27-97) <br />