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SAN JOAQUIN Cr -Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL HF 'N DIVSION <br /> U ;ROUND STORAGE TANK PROGRAM - FEE WORKSHEE' <br /> S FACILITY ITE NAME FACILITY CONTACT NAME <br /> I S <br /> T <br /> -E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & vS a (r - <br /> A CITY STATE ZIP CODEO� # of TANKS 2 <br /> at SITE J <br /> P <br /> P APPLICANT LING N APPLICANT CONTACT NAME <br /> < < o _ �j3 -zs525 <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N <br /> 6 h <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> 0 OA GJJ- (Closure, Installation, etc.) hJA <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 $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX E XXXXXXXX <br /> 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 7988 1989 1990 1991 19921993 1994 1995 1996 1997 1 1998 <br /> F (multipLy # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX S <br /> L 4 <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 S <br /> T <br /> Y # Tanks_ x $8.00 1988 through 1993 ($56) 1993 through 1997 ($56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TA X $234.00 = $ <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.0. #(s <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> PINSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A �r/ [, <br /> M PLAN CHECK FEE _ $78.00/hour (8 hours minimus/FACILITY) _ $624.00 minimus f <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours mini mum/TANK) # TANK(s) X 5234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ <br /> FOR OFFICE USE <br /> az_ • ' TOTAL DUE S <br /> ONLY <br /> ............i.l.!.i.i.i.li...._.......... <br /> _.._..... <br /> : <br /> iFF:�:ii!! ..!.!.!.!...i.e.e.e.!.eii!iii!o!iii!3 _ ci— <br /> SWEEPS . <br /> # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> EH 23 032 (REVISED 1-12-98) <br />