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0 <br />A <br />P <br />P <br />L <br />I <br />C <br />A <br />N <br />T <br />SAN JOAQUINPUBLIC HEALTH SERVICES - ENVIRONMENTAL DIVSION <br />UND OUND STORAGE TANK PROGRA14 - FEE WORKSHEET <br />FACILITY SITE NAME <br />45U pe"4 <br />FACILITY CONTACT NAME <br />Sb ® `® i <br />FACILITY ADDRESS <br />o. AlZvoq <br />SITE PHONE # with AREA CODE <br />44-7!r <br />CITY <br />ST TE <br />ZIPCODE <br />TANKS <br />at SITE <br />SITE <br />APPLI NT/BIL ING NAME „,, <br />APPLICAN CONTACT NAME <br />1 <br />MAILING A ESS <br />APPLICANT PHONE # WITH AREA CODE <br />CIT, <br />7E <br />ZIP CODE <br />TYPE of APPLICATION 1 1 n f111\i <br />(Closure, Installation, etc.) (- <br />TOTAL <br />TOTAL DUE $ <br />FOR OFFICE USE ONLY <br />EH 23 032 (REVISED 5-27-97) <br />1986 1987 <br />1988 <br />1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />A <br />XXXX XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXX <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXX <br />I <br />V <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />$170/TANK (After <br />January 1, 1991) <br />E <br /># Tanks = 1987 1988 1989 1990 1991 <br />1992 1993 1994 <br />1995 1996 1997 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) XXXX XXXX XXXX XXXX XXXX <br />$ <br />C <br />I <br />TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX <br />$ <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 <br />1$ <br />T <br />Y <br /># Tanks x $8.00 1988 through 1990 ($56) <br />1991 through 1996 ($56) 1997 <br />SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />5 <br />C <br />PERMANENT CLOSURE (Removal'or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minim/TANK) <br /># TANK(s) X <br />$234.00 = <br />S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minim/FACILITY) <br />$234.00 minimum <br />$ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minim/FACILITY) <br />= $624.00 minim <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= $234.00 minim <br />$ <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minim <br />$ <br />M <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />$ <br />I <br />S <br />C <br />CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br />= 578.00/hr <br />$ <br />TOTAL DUE $ <br />FOR OFFICE USE ONLY <br />EH 23 032 (REVISED 5-27-97) <br />