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SAN JOAQUIN C LIC HEALTH SERVICES - ENVIRONMENTAL HEAL IVSION <br />UNDE OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />A—e,51/ <br />"y-Lz <br />V <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />1989 <br />1990 <br />L <br />0 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />0 TANK(s)_ -- X S234.00 <br />T <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />E <br />FACILITY A D ES <br />SITE PHONE 9 with AREA CODE <br />( SAMPLING INSPECTION FEE = S78.00/hr <br />A <br />U <br />XXXX <br />XXXX XXXX <br />XXXX <br />XXXX S XXXXXXXX <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimus <br />R <br />CITY <br />STATE <br />ZIP CODE <br />9 of TANKS <br />A <br />5234.00 minimum <br />IL <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />at SITE <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX I XXXX <br />P <br />XXXX S XXXXXXXX <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />I <br />V <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) -g <br />I <br /># Tanks = <br />1987 <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE Al WITH AREA CODE <br />A <br />Hjr,3 <br />1994 1995 <br />1996 <br />���G <br />1997 C f�{I <br />F <br />A <br />N <br />XXXX <br />XXXX <br />XXXX <br />XXXX XXXX <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />(Closure, Installation, etc.) <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />1986 <br />1987 11988 <br />1989 <br />1990 <br />L <br />0 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />0 TANK(s)_ -- X S234.00 <br />rn <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />S <br />S <br />S <br />( SAMPLING INSPECTION FEE = S78.00/hr <br />A <br />U <br />XXXX <br />XXXX XXXX <br />XXXX <br />XXXX S XXXXXXXX <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimus <br />R <br />E <br />C <br />5234.00 minimum <br />IL <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />S <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX I XXXX <br />XXXX <br />XXXX S XXXXXXXX <br />I <br />V <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) -g <br />E <br /># Tanks = <br />1987 <br />1988 <br />1989 <br />1990 1991 <br />1 <br />Hjr,3 <br />1994 1995 <br />1996 <br />���G <br />1997 C f�{I <br />F <br />A <br />(multiply # by fee for <br />each year applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX XXXX <br />�'7v <br />17C) <br />1'70)'70 <br />U7� <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />XXXX `XXXX <br />/ <br />/70' % 0 <br />/O <br />1 7O S <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 Is <br />T <br />Y <br />Tanks x $8.00 <br />1988 through 1990 (S56) <br />1991 through 1996 (S56) <br />19917' <br />VA 04-514 <br />SURCHARGE FOR 1997 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK l.D. #(s) <br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />L <br />S <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />0 TANK(s)_ -- X S234.00 <br />rn <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />S <br />S <br />S <br />( SAMPLING INSPECTION FEE = S78.00/hr <br />( <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. ff(s) <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimus <br />R <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />IL <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />TANK I.D. 0(s) <br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />L <br />S <br />E <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. 0(s) <br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />S <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />9 TANK(s) X $234.00 = <br />S <br />( SAMPLING INSPECTION FEE = S78.00/hr <br />( <br />S <br />A <br />S <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimus <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />S <br />M <br />TRANSFER FEE = $20.00 <br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />S <br />I <br />S <br />C <br />CONSULTATION FEE = 578.00/hr <br />( SAMPLING INSPECTION FEE = S78.00/hr <br />( <br />S <br />TOTAL DUE <br />S <br />FOR OFFICE USE ONLY <br />SWEEPS # I COMPUTER X I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK X/CASH <br />S <br />EH 23 032 (REVISED 5-27-97) <br />RECEIVED BY I DATE RECEIVED <br />0 <br />51 <br />