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SAN JOAQUIN COON . 71i8�_.. HEALTH SERVICES - ENVIRONMENTAL HEAL <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> I <br /> S FACILITY-317E NAME <br /> fACI L [ TY CONTACT NAME <br /> I S� ttoa <br /> T <br /> " E FACILITY ADDRESS <br /> SITE PHONE # with AREA CODE <br /> & cJb <br /> CITY STATE ZIP CODE # of TANKS <br /> Ai 9S� / at SITE ZJ <br /> P [ }� <br /> APPLICA ILLING NAME APPLICANT CONTACT NA <br /> I 1 L (G <br /> Zortbo <br /> A M LING 0.0DRESS APP =T P i WITH CODE <br /> N <br /> � . G`F SQ D <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> C� � l ( Closure , Installation , etc . ) <br /> TOTAL <br /> 1986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE ( Prior to January 1 , 1991 ) = 5100 . 00 <br /> %XXX %XXX XXXX XXX% %XXX 2 %XXXX%%% <br /> A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED ( If Applicable) %XXX XXXX XXXX XXXX X%%X S %%%XXXX% <br /> I <br /> V TANK FEE = 250 . 00/TANK (Prior to January 1 , 1991 ) S170/TANK (After January 1 , 1991 ) <br /> E <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 11996 11997 1998 <br /> F (multiply # by fee for <br /> A each year applicable ) XXXX XXXX XXXX XXXX ( XXXX I I S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXX% XXXX XXXX %XXX I I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518 . 50 S <br /> T <br /> Y # Tanks_ x $8 . 00 1988 through 1993 (256 ) 1993 through 1997 (256) 1998 <br /> SURCHARGE FOR 1998XX%XXXXXXXXXXXXX%xxxxxxxXXX XXXXXXXXXXX% <br /> XXXXXXXXXXX S <br /> C PERMANENT CLOSURE ( Removal or Authorized C ( osure- in- P Lace ) I TANK LD . #( s ) <br /> L <br /> 0 CLOSURE FEE = 578 . 00/hour ( 3 hours minimum/TANK ) I # TANK( s ) X 5234 . 00 = S 5SIDS . <br /> S <br /> U TEMPORARY CLOSURE ( Plan Review & Inspections ) TANK I . D . x( S ) <br /> R <br /> E TEMPORARY CLOSURE FEE = 278 . 00/hour ( 3 hours minimum/ FACILITY) 2234 . 00 mini mum S <br /> PELAMZ <br /> E = 278. 00/hour (8 hours mininumn/ FACILITY ) 2624 . 00 mininum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections ) TANK I . D . #( s ) <br /> E <br /> P TANK LINING REPAIR FEE = 278 . 00/hour (3 hours minimum/TANK) # TANK( s ) % 5234 . 00 = S <br /> A <br /> I TANK. RETROFIT REPAIR FEE 578 . 00/hour (3 hours min. /FACILITY ) = 2234 . 00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578 . 00/hour (3 hours minimum/FACILITY) = $234 . 00 minimum S <br /> M TRANSFER FEE = 220 . 00 UNAUTHORIZED RELEASE EVALUATION = 278.00/hr I I S <br /> I 1 <br /> S <br /> C CONSULTATION IEE = 278 . 00/hr I SAMPLING INSPECTION FEE = 578 . 00/hr S <br /> TOTAL DUE S 36 DVI <br /> FOR OFFICE USE ONLY <br /> ..::- <br /> ................_..._........,.. ... .......... _.. ................_..................._..._ . <br /> zmm:e_cz�s;:cse':::a::;;:�a_a;::::-es::_ s:: su_.__:a_ :_ w— u::=__z:_ter__ __::-::c::::;- :�; :_aa=- -__ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED I CHECK 9/CASH RECEIVED 3Y DATE RECEIVED <br /> Fu 77 nl? rRFVISED 1 - 12- 98 ) <br />