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`x <br /> SAN JOAQUIN COUNTIJI&MLIC HEALTH SERVICES - ENVIRONMENTAL HEALT12MICH <br /> UNOERjW STORAGE TANK PROGRAM - FEE WORKSHEET <br /> I; FACILITY SITE NAME I FACILITY CONTACT NAME r S <br /> T ` c- <br /> �t 'f <br /> Ei FACILITY ADDRESS SITE PHONE » with AREA =E <br /> ® S. t t/'4 G C I 3s— — / <br /> CITY STATE ZIP CODE # of TANKS <br /> A l V-4 C- I I 5'S37 4 I at SITE <br /> P <br /> p APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS I APPLI ANT RHONE ;* WITH AREA CODE <br /> N 5 <br /> TlC -'' I TEI ZIP CODE PLICATION <br /> (Closure Installation, etc.) <br /> TOTAL <br /> I 11986 ( 1987 11988 11989 11940 <br /> AlANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> XXXX I XXXX XXXX I XXXX I XXXX S XXXXXXXX <br /> C' 1 <br /> T! FACILITY PEVALTY FEES ASSESSED (if Applicable) XXXX j XXXX I XXXX XXXX I XXXX 5 XXXXXXXX <br /> I� <br /> YI TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E' <br /> Tanks = 11987 , 1988 1989 11990 11991 11992 11993 11994 11995 11996 11997 <br /> F (multipLy py fee for <br /> A each year applicable) I XXXX I XXXX XXXX XXXX XXXX 5 <br /> l I I I I 1 5 <br /> Ii TANK PENALTY FEES ASSESSED I XXXX � XXXX I XXXX I XXXX (XXXX <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 �5 <br /> T <br /> YI T Tanks x 58.00 I 1988 through 1990 (S56) 1991 through 1996 (556)1 1997 <br /> I <br /> SURCHARGE FOR 1997 I XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> Ci PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) I TANK I.D. :(s) <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I T TANK(s) X 5234.00 - S <br /> S !!! <br /> U� TEMPCRARY CLOSURE (?Lan Review & Inspections) I TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum 5 <br /> P) INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)) TANK I.D. 4(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction inspections) I TANK 1.0. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> N) TRANSFER FEE = 520.00 I I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I 5 <br /> I I I I I <br /> S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = S78.00/hr I I S <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> SWEEPS I COMPUTER I LOC CODE I DISTCODEI AMOUNT RECEIVED CHECK :/CASH RECEIVED 3Y I DAT RECEIVED <br /> r S <br /> EH 23 032 (REVISED 5-27-97) <br />