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SAN JOACUIN adbry PUBLIC HEALTH SERVICES - ENVIRONMENTALH DIVSION <br /> GROUND STORAGE TANK PROGRAM - FEE WORKSH <br /> S FACILITY TE V E FACILITY CO TACT NAM <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREWCODE <br /> p <br /> CITY STATE ZIP CODE # of TANKS <br /> A o at SITE <br /> P <br /> P APPLICANT/BILLING N E I APPLICANT CONTACT <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT P E''# WITH AREA CODE ✓� <br /> N D ` <br /> T CITY STATE) ZIP CODE I TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1 1 1 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 1986 1987 1988 1989 1990 <br /> A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX XXXX XXXX I XXXX I XXXX $ XXXXXXXX <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) I $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 11987 1988 1989 11990 1991 , 1992 1 1993 1994 + 1995 11996 1997 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX ,XXXX I I ( I $ <br /> I TANK PENALTY FEES ASSESSED I XXXX I XXXX XXXX I XXXX IXXXX <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 p$ <br /> T <br /> Y # Tanks x 58.00 1988 through 1990 (S56) 1991 through 1996 (S56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ <br /> CI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <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) I 5234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P1 TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum 5 O <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum 5 <br /> M TRANSFER FEE _ $20.00 I UNAUTHORIZED RELEASE EVALUATION = $78.00/hr i $ <br /> I <br /> S <br /> Ci CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = $78.00/hr I I $ <br /> TOTAL DUE $ y(a p <br /> FOR OFFICE USE ONLY <br /> ( €i =:. ..... . €_ :i4SWEEPS COMPUTER # LOC CODE DIST CODE-.f <br /> AMOUNT RECEIVED ( CHECK #/CASH RECEIVED BY ( DATE RECEIVED <br /> s- <br /> W <br /> EH 23 032 (REVISED 5-27-97) <br />