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SAN JOAQUIN COIPUBLIC HEALTH SERVICES - ENVIRONMENTAL HE* DIVSION UNDE GROUND STORAGE TANK PROGRAM - FEE WORKSHEET S FACILITY SITE NAME C l= N FACILITY CONTACT NAME J T E 1986 1987 1988 1989 E FACILITY ADDRESS SITE PHONE # with AREA CODE # TANK(s) X $234.00 = ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S A CITY (nSTATE C&- ZIP CODE /o # of TANKS at SITE PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum R 75.33 { A P E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) P APPLICANT/BILLING NAME APPLICANT CONTACT NAME. L I XXXX XXXX $ XXXXXXXX I C MAILING ADDRESS I� �i� APPLICANT WONE # WITH AREA CODE A09 — to —&337 ?S 3S • N C T CITY �STATE 1-1Q . ZIPP CODE /52 D S TYPE of APPLICATION (Closure, installation, etc.) TOTAL C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) E 1986 1987 1988 1989 1990 O CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum R A E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum XXXX XXXX XXXX I XXXX XXXX $ XXXXXXXX C T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX I XXXX XXXX $ XXXXXXXX I VI _ _ TANK FEE _ $50.00/TANK (Prior to January 1,1991) I $170/TANK (After January 1, 1991) E # Tanks = 1988 1989 1990 11991 11992 1993 1994 1995 1996 1997 1998 F (multiply # by fee for $ ��. O O A each year applicable) XXXX XXXX I XXXX I XXXX (XXXX I C I TANK PENALTY FEES ASSESSED XXXX I XXXX XXXX XXXX XXXX $ L I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 $ T Y # Tanks x $8.00 1988 through 1993 ($56) 1993 through 1997 ($56) 1998 SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ O b C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) E L P A TS O CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum R E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) E L P A TS N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum 4;-q. O 0 R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) E P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) I # TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ R PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ M TRANSFER FEE _ $20.00 I S C CONSULTATION FEE _ $78.00/hr UNAUTHORIZED RELEASE EVALUATION = $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr FOR OFFICE USE ONLY SWEEPS # I COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK WASH $ EH 23 032 (REVISED 1-12-98) 5 $ TOTAL DUE $ J g, o D RECEIVED BY I DATE RECEIVED ►/J