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SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH DIVSION <br /> GROUND STORAGE TANK PR - FEE WORMH <br /> S FACILITY SITE NAMEFACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY D ES 04 SITE PHONE # with AREA CODE <br /> & <br /> CITY STATE ZIP CODE # of TANKS <br /> A G at SITE <br /> P <br /> P APPLICANT/EJILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I e <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A =a XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX i XXXX I I I S <br /> L <br /> I STATE SURCHARGE _ <br /> T <br /> Y # Tanks x $8.00 1988 through 1990 (S56) 1991 through 1996 (S56) 1997 <br /> SURCHARGE FOR 1997 xxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx S <br /> C PERMANENT CLOSURE (Removal 'of Authorized Closure-in-Place) TANK I.D. #(s) <br /> L AV <br /> 0 <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> S S2 E <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.A. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minim S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minim 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minim S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr =SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S O O <br /> FOR OFFICE USE ONLY <br /> SWEEPS ` I COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED ` CHECK #/CASH RECEIVED BY I DATE RECEIVED 3 <br /> EH 23 032 (REVISED 5-27-97) ?J <br />