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I <br /> SAN JOAQUIN CrPUBLIC HEALTH SERVICES - ENVIRONMENTAL HE' ° DIVSIGN <br /> U AOUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> IFAC [ TYiSI ?E NAME � ACILITY WN AC,7 ME ` u <br /> T 1/.L/ 9/ AveU� /N <br /> ' E FpC ILITY ADORES /o S TE PHONE k with ARP WOE <br /> & <br /> CIT SSAiE ZIP CWE 7 of TANKS <br /> A at SITE <br /> P T <br /> P APP ICANITA/BILLING NAME APPLICANT WNTA¢F NAME <br /> C MAILING ADDRESS ICANT PHONE 0 WITH AREA CODE <br /> A2t 1 S Z 1 4 • I ) - L16S, 3 <br /> N <br /> S TE ZIP CODE TYPE of APPLICATION <br /> T C1T ULI 1� <br /> T4L)' ( Closure , Installation , etc. ) P` Jo '✓1bt/L. / <br /> TOTAL <br /> 1986 11987 11988 11989 1990 <br /> ANNUAL FACILITY FEE ( Prior to January 1 , 1991 ) = 5100 . 00 <br /> A xxxx xxxx xxxx XXXx XX%x S Xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED ( If Applicable ) I Xxxx xxxx I xxxx xxxx xxxx S XXXXXxxx <br /> I - - <br /> V TANK FEE = S50 . 00/TANK (Prior to January 1 , 1991 ) 5170/TANK (After January 1 , 1991 ) <br /> E <br /> Y Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 ( 1996 11997 1998 <br /> F (multiply N by fee for <br /> A each year applicable ) Xxx% xxxx X%%x %XXX %XX% I I 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx I xxxx I xxxx IXxxx I I i I I S <br /> I <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=S18 . 5O S <br /> T <br /> Y # Tanks_ x 38 . 00 1988 ch rough 1993 (356 ) 1993 ch rough 1997 ( 556) 1998 <br /> SURCHARGE FOR 1998 %xxxxxxxx%xxxXxxxxxxxXXX%xX XXX%X%X%%XX%xX%XXXXX%%X S <br /> C PERMANENT CLOSURE ( Removal or Authorized Closure- in-Place) I TANK 1 , 0 . Y( s ) <br /> L <br /> O CLOSURE FEE = 578 . 00/hour ( 3 hours minimum/TANK ) B TANK( s ) X 5234 . 00 <br /> S <br /> U TEMPORARY CLOSURE ( Plan Review 3 Inspections ) TANK I .D . k( s ) <br /> R 1 EI TEMPORARY CLOSURE FEE = S78 . 00/hour (3 hours minimum/ FACILITY ) I 5234 . 00 minimum S <br /> PEI <br /> TALLATION PLAN CHECK ( Plan Review & Constructien Inspections ) TANK L0 . X( s )LANN CHECK FEE = 378 . 00/hour (8 hours minimum/ FACIE ITY7 = 5624 .00 mini m:m 3 <br /> R REPAIR FEE (Workplan Review & Construction Inspections ) I TANK I . O . X( s ) <br /> E <br /> P TANK LINING REPAIR FEE = 578 . 00/hour (3 hours minimum/TANK) # TANK( s ) X 5234 . 00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578 . 00/hour ( 3 hours min. / FACILITY ) = $234 . 00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578 . 00/hour (3 hours minimum/ FACILITY) = 5234 . 00 minimum 5 <br /> M TRANSFER FEE = 320 . 00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I <br /> S <br /> ClCONSULTATION FEE = S78 . 00/hr I I SAMPLING INSPECTION FEE = E78 . 00/hr E <br /> TOTAL DUE <br /> FOR OFFICE USE ONLYAn <br /> SWEEPS X COMPUTER R LOC CODE DIST CODE AMOUNT RECEIVED CHECK d/CASH RECEIVED BY DATE RECEIVED <br /> s. <br /> s I <br /> cu 7S O't7 ( RFVISFD 1 . 12-98 ) <br />