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SAN JOACUIN COUNT! PUBLIC HEALTH SERVICES - e(VIRONMENTAL HEALTH OIVSION <br />(N(0 STORAGE TANK. PROGRAM - FEE WRKSHEET db <br />FACILLTY SITE NAME _i %`� N c�� /f CJOLr <br />FACILITY CCNTA NAME <br />ffs'l <br />noT _si�i��Pe _s i <br />.�1/U�ic /5 cl nl.S ON <br />St E PHONE A with AREA CCOE <br />FACILITY AOOR£SS <br />7-h( IOCD <br />ZIP <br />CODE of TANKS <br />A <br />CITY �j <br />�% %7r�/ I <br />CEI <br />I <br />at SITE <br />P <br />p <br />ApotICANT/BILLING NAME <br />I APPLICANT CONTACT NAME <br />I <br />APPLICANT PHONE WITH AREA CME <br />C <br />HAILING AOORESS <br />N <br />STAT'c <br />ZIP CCOEP£�f�PQLICATION <br />T) <br />CITY <br />I (CLosure,,tnstaLLac ion, etc.) <br />TOTAL <br />1986 1487 � 1988 11984 11990 <br />ANNUAL FACILITY F=-=-(Prior to January 1, 1991) = 5100.00 <br />f <br />I XXXX I XXXX XX)X XXXX i xxxx <br />S XXXXXXXX <br />A <br />CI <br />T� FACILITY PENALTY FEES ASSESSED ([f Applicable) <br />I <br />XXXX , XXXX xxxx I xxxx XXXX <br />S XXXXXXXX <br />I <br />TANK FEE = s50.00/TANK (Prior to January 111991) <br />5170/TANK (Atter January 1, 1991) <br />t1988 <br />T Tanks = <br />11989 11990 11991 11992 11993 <br />11994 11995 <br />11996 11997 11998 <br />by fee <br />(muiPLY <br />tyear <br />XXXX I XXXX I XXXX I XXXX XXXX <br />S <br />app(icaole)r <br />A <br />C� <br />I TANK PENALTY FEES ASSESSED l <br />XXXX , XXXX ( XXXX XXXX XXXX I <br />! <br />5 <br />L <br />STATE SURCHARGE FOR NEU FACILITIES ONLY=518.50 <br />S <br />y <br />I <br />T Tanks x 33.00 <br />1988 thrcugh 1993 (S56) <br />1993 through 1997 (556) 1998 <br />SURCHARGE FOR 1998 <br />I xxxxxxxxxxXXXXXXXXXXXXXXXXX <br />XXXXXxxxxxxxxxxxxxxxxxx <br />S <br />Cl PERMANENT CLOSURE (Removal or Autharized Closure-in-PLace) ( <br />TANK I.17. =(s) <br />L1 <br />Oj CLOSURE FEE = 578.00/hour (3 hours miniaxan/TANK) <br />: TANK(s) X 5234.00 = <br />S 1, <br />-7k- <br />7k-S <br />Si <br />UI TEMPORARY CLOSURE (?Lan Review & inspections) <br />TANK I.D. �(S) <br />R <br />E TEMPORARY CLOSURE F-c_ = 578.00/hour (3 hours minims=/FACILITY) ; <br />5234.00 minimum <br />5 / <br />Yl <br />Review & Construction Inspections)) <br />TANK I.O. T(S) <br />PI INSTAL .1TiON PLAN CHECK (?(an <br />L <br />A <br />NJ ?LAN CHECK FE. = 578.00/hour (8 hours minimum/FACILITY) <br />= 5624.00 minimus <br />5 <br />RI REPAIR F_E (Workplan Review & Construction Inspections) <br />- <br />TANK i.0. »(s) <br />E <br />p <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimunITANK) , <br />4 TANK(s) X 5234-00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 mini nun <br />- <br />5 <br />R <br />_ <br />?(PING REPAIR FEE = 578.00/hour (3 hours minime.m/FACILITY) <br />- 5234.00 minimum <br />S <br />Ml TRANSFER FEE = 520.00 UNAUTHORIZED RELEASEE EVALUATION = 573.00/hr <br />S'-- <br />Cl CONSULTATION FEE = 578.00/hr ` I SAMPLING INSPECTION r-Ec <br />= 578.00/hr <br />I <br />3 <br />TOTAL DUE <br />S 4/Aft/ G <br />OFFICE USE ONLY <br />COMPUTER ( LOC CODE , OIST CODE + AmCUNT REC-EIVED <br />+ CHECK ./CASH + REC iV© By OAT'c RE :INFO <br />5 <br />j I <br />-- ---- - <br />z -H 23 032 (REVISED 1-12-98) <br />