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0_,O' <br /> SAN JOAQUIN a PUBLIC HEALTH SERVICES - "AMOWMEiTAL H DiVsiou <br /> UNSDOUND STORAGE TANK PROGRM FEE 6�)RKSHEETT* <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS SITE PHCNE W' with AREA CODE <br /> ZLIU <br /> CITY STATE ZIP CODE # of TANKS <br /> P -Z at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Li <br /> C! MAILING ADDRESS APPLICANT PHONE R WITH AREA CODE <br /> Aj <br /> N <br /> TI CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, :nstatiazion, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 11 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A I xxxx I xxxx xxxx xxxx xxxx $ xxxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I xxxx xxxx xxxx xxxxxxx x "I S xxxxxxxx <br /> VI TANK FEE = S50.00/TANK (Prior to January 1,1991) I 5170/TANK "After January 1, 1991) <br /> E <br /> Tanks = 1987 11988 1989 i 1990 1991 1 1992 1993 1994 i 1995 1 1996 1997 <br /> Fj (multiply # by fee for <br /> Al each year applicable) xxxx xxxx Xxxx xxxx xxxx J S <br /> C <br /> 11 TANK PENALTY FEES ASSESSED XXXX XXXX XXxX xxxx jxxxx I I $ <br /> it <br /> L ---------- ------------- <br /> I - -1 <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $13.50 S <br /> T <br /> Y! '#' Tanks x $8.00 1988 through 1990 (556) i991 through 1996 ($56) 1997 <br /> SURCHARGE FOR 1997 <br /> XXXXXXXXXXXXXXXXXXXXXXXXXXX xxxxxxxxxxxxxxxxxxxxxxx S <br /> ji C! PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. 4(s) <br /> L <br /> ii Ci CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 S <br /> Ul TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. ;+(s) <br /> El TEMPORARY CLOSURE FEE = S78.010/hour (3 hours minimum/FACILITY) $234.00 minfiwum S <br /> P j INSTALLATION PLAN CHECK (Plan Review & construction inspections)i TANK I.O. #(s) <br /> NJ PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 minimus S <br /> RI REPAIR FEE (Workplan Review L Construction inspections) TANK I.O. ;*(s) <br /> El <br /> P! TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) 4 TANKCs) x 5234.00 = a S <br /> A, <br /> 11 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) $234.00 minimum S <br /> MI TRANSFER FEE = 520.00 � UNAUTHORI"LED RELEASE :VALUATION = 57$.00/hr i !I S <br /> C4 CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION 578.00/hr <br /> S <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> ....................... ...... ....... .................-.................... ........... ..................... <br /> :;:;z;;:;::;::: ::::::: .. . - -...... ..... .... ........... <br /> ............................t �:::::::i:::---1-1 .1.---;::;:: <br /> .......... ............. ................................. ................ <br /> SWEEPS 9 COMPUTER 4 LOC CODE DIST CODE AMOUNT RECEIVED j'CHECK 4/CASH RECEIVED SY DATE RECEIVED <br /> t <br /> ...........................__......1.................................. ...................... ........... ............. <br /> ................ .......... ............... <br /> ...............................I.......................... ............ <br /> ................. . ........ ............... <br /> .......................... ............................... ................ <br /> E.4 23 032 (REVISED 5-27-97) <br /> 1 <br />