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y SAN JOAQUIN aljLTY PUBLIC HEALTH SERVICES - ENVIRONMENTALH DIVSION <br /> OUND STORAGE TANK PROGRAM - FEE WORKSHE 0 <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T (cul`/G .S TO/' Crura Prrc•fi 1V/92�i �1I2b�t'�} <br /> "E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & as 85 c, F2Ernvn-F S+t 1=F-+ 6av9 -116y- 1038 <br /> CITY 1 i` STATE ZIP CODE # of TANKS <br /> A S cK CM C/9 d0s- at SITE ;-P <br /> P <br /> P APPLICAN $SME- APPLICANT CONTACT NAME <br /> L <br /> I t t..�a I+&A S"6-, Y1 r'C to "kv )v hn 1 Ice- t_ <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N C h o tea S 9/6 3 3 - //6 8 <br /> T CITY STATE ZIP DE T <br /> COYPE of AP N <br /> WC6+ 5 19G W m�r�'T© CSF `�S6 �/ (Closure, tnstallation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX I XXXX XXXX $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = Zk, 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 of Shc� <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 XXXX $ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 S "OV4 <br /> T <br /> Y # Tanks_ y x 58.00 1988 through 1993 ($56) 1993 through 1997 (S56) 1998 01 D <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX s 16, — <br /> C <br /> 6CPERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> S <br /> U) TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = s <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum 5 <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr $ <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br />:.--:-w ,� •_.�-,..,_ .:: =._, _ -� M�--M•_�•: -. --max.. ---�:__:-::-.- w•�__ _. -—. -.--_ r: — --� <br /> 3s SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED . <br /> ss <br /> S - <br />._».__....._.........._._........._......._......_____ max..=�=........_._:�....:-__......._..___._._..::....�........__._..._._._-_::_::.:._.........._ .:..�.•-._...._. .._..._._.;...=_:::::�-s:�.:::::w._.. <br /> EH 23 032 (REVISED 1-12-98) • <br />