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' SAN JOAQUINOTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH OIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />SI <br />FACILITY S TE NAME <br />FACILITY CONTACT NAME <br />I <br />39s <br />1988 <br />T <br />, 1990 <br />E <br />FACILITY ADDRESS <br />I SITE PHONE # with <br />CODECe <br />&I <br />/AREA <br />�y <br />CITYTATE ZIP <br />CODE # of TANKS <br />A <br />TANK I.D. #(s) <br />at SITE <br />P, <br />XXXX <br />XXXX <br />Pi <br />APPLICANT/B LLING N APPLI- NT CONTACT NAME q <br />II <br />5234.00 minimum S <br />Ci <br />MAILING ADDRESS, <br />APPLICANT PHONE # WITH AREA CCODE a <br />Al <br />L� <br />J a <br />® ®44 /'"^ 6, 33 7 <br />N, <br />71 FACILITY PENALTY FEES ASSESSED ('.f Applicable)( <br />Tj <br />CITY TATER ZIP CODE TYPE of APPLICATION h <br />i <br />j XXXX i <br />7' (Closure, Installation, t� <br />i tu=r__ !I <br />TOTAL <br />Ci <br />PERMANENT <br />CLOSURE (Removal or Authorized Closure - in -Place) I <br />1986 <br />i 1987 <br />1988 <br />1989 <br />, 1990 <br />i ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />= 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = S <br />sl <br />' <br />Aj <br />CLOSURE (Plan Review 8 inspections) I <br />TANK I.D. #(s) <br />( XXXX <br />i XXXX <br />XXXX <br />XXXX <br />( XXXX <br />S XXXXXXXX <br />C: <br />5234.00 minimum S <br />71 FACILITY PENALTY FEES ASSESSED ('.f Applicable)( <br />XXXX <br />XXXX <br />j XXXX i <br />XXXX <br />! XXXX <br />S XXXXXXXX <br />I <br />Vf TANK FC_ = 550.00/TANK <br />(Prior to January 1,1991) <br />S170/TANK <br />(After <br />January <br />i, <br />1991) <br />E' <br />i # Tanks = <br />1 1987 i 1988 11 1989 <br />1990 <br />1991 1 <br />1992 ;993 <br />1994 <br />11995 i <br />1996 <br />1 1997 <br />F! (multiply # by fee for <br />I XXXX <br />XXXX <br />p 5 <br />AI each year applicable) ' XXXX I XXXX i XXXX <br />C' <br />II TANK PENALTY FEES ASSESSED <br />I XXXX I XXXX XXXX I XXXX <br />;XXXX <br />I <br />I <br />p S <br />L' <br />Ij STATE SURCHARGE FOR NEW FACILITIES ONLY = 518.50 <br />S <br />T' <br />Y; ;Tanks x 58.00 <br />1988 through 1990 <br />(S56) <br />1991 through <br />1996 (S56) <br />1997 <br />w <br />SURCHARGEFOR 1997 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />Ci <br />PERMANENT <br />CLOSURE (Removal or Authorized Closure - in -Place) I <br />TANK i.D. #(s) <br />C <br />CLOSURE FEE <br />= 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = S <br />sl <br />UI <br />TEMPORARY <br />CLOSURE (Plan Review 8 inspections) I <br />TANK I.D. #(s) <br />R <br />El <br />TEMPORARY <br />CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) I <br />5234.00 minimum S <br />P1 INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />Al <br />N1 PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br />S <br />MI TRANSFER FEE = $20,00 UNAUTHORIZED RELEASE EEVALUATION = 578.00/hr I i q S <br />I. N <br />S' <br />Cj CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr I I S <br />TOTAL DUE S ,3 �( a L) Q <br />FOR OFFICE USE ONLY <br />SWEEPS COMPUTER # I LOC CODE <br />EH 23 032 (REVISEED 5-27-97) <br />DIST CODE I AMOUNT RECEIVED I CHECK #/CASH I RECEIVED 3Y <br />IS i I <br />DATE RECEIVED <br />