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S <br />I <br />T <br />E <br />E <br />A <br />P <br />P <br />L <br />I <br />C <br />A <br />N <br />T <br />SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTALDIVSION <br />jjPkROUNO STORAGE TANK PROGRAM - FEE WORKSN <br />FACILITY SITE NAME <br />/ <br />FACILITY CONTACT NAME <br />7 <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />TANK I.D. #(s) <br />at SITE <br />APPLICANT/BILLINGNAME <br />APPLICANT CONTACT NAME <br />/ <br />1989 <br />MAILING ADDRESS <br />APPLICANT ONE # WITH EA CODE <br />JZZ <br />7 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />�.I K <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />(Closure, Installation, etc.) <br />C <br />L <br />O <br />S <br />U <br />R <br />E <br />P <br />L <br />A <br />N <br />R <br />E <br />P <br />A <br />I <br />R <br />M <br />I <br />S <br />C <br />PERMANENT CLOSURE (Removal br Authorized Closure - in -Place) <br />TANK I.D. #(s) <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK)f <br /># TANK(s) 2 -^"" <br />X $234.00 = 6 <br />$ <br />70 <br />TOTAL <br />TANK I.D. #(s) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />= 5624.00 minim <br />TANK I.D. #(s) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) <br />X $234.00 = <br />5 <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />A <br />$ <br />PIPING REPAIR FEE = 578.00/hour (3 hours minim/FACILITY) = $234.00 minim <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXX <br />CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br />TOTAL DUE <br />$ <br />$ <br />j <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />$ XXXXXXXX <br />I <br />V <br />TANK FEE = 550.00/TANK <br />(Prior to January 1,1991) <br />5170/TANK <br />(After <br />January 1, 1991) <br />E <br /># Tanks = <br />1987 1988 1989 1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />1997 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />XXXX XXXX XXXX XXXX <br />XXXX <br />$ <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX XXXX XXXX XXXX <br />XXXX <br />$ <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 <br />1$ <br />T <br />Y <br /># Tanks x $8.00 <br />1988 through 1990 <br />($56) <br />1991 through <br />1996 <br />($56) <br />1997 <br />SURCHARGE FOR 1997 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />S <br />C <br />L <br />O <br />S <br />U <br />R <br />E <br />P <br />L <br />A <br />N <br />R <br />E <br />P <br />A <br />I <br />R <br />M <br />I <br />S <br />C <br />PERMANENT CLOSURE (Removal br Authorized Closure - in -Place) <br />TANK I.D. #(s) <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK)f <br /># TANK(s) 2 -^"" <br />X $234.00 = 6 <br />$ <br />70 <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />$234.00 minim <br />TANK I.D. #(s) <br />$ <br />PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />= 5624.00 minim <br />TANK I.D. #(s) <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) <br />X $234.00 = <br />5 <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= $234.00 minim <br />$ <br />PIPING REPAIR FEE = 578.00/hour (3 hours minim/FACILITY) = $234.00 minim <br />TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />$ <br />$ <br />CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br />TOTAL DUE <br />$ <br />$ <br />j <br />FOR OFFICE USE ONLY <br />it V <br />SWEEPS # I COMPUTER # I LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br />5 <br />......................... <br />EH 23 032 (REVISED 5-27-97) <br />