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+w} <br /> SAN JOAQUIN Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL HDIVSION <br /> U _ GROUND STORAGE TANK PROGRM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 152 <br /> E FACILITY sADDRESS SITE PHONE # with AREA CODE <br /> & (d <br /> CITY STATE ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT BILLING NAME APPLICANT CONTACTE <br /> I t(��+ <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N r2 357 ✓t • 4209- Cor - (- 337 <br /> T CITYd��U STATE ZIP CODE TYPE of APPLICATION <br /> CfSz® — (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 1986 1987 1488 1989 1990 <br /> A XXXX XXXX I XXXX 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 = 1987 1988 1989 1990 1991 1992 1993 1994 11995 1 1996 1997 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX I XXXX I XXXX XXXX XXXX I I $ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 is <br /> T <br /> Y # Tanks x 58.00 1988 through 1990 ($56) 1941 through 1996 ($56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minim/FACILITY) 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 = 578.00/hour (8 hours minim/FACILITY) _ $624.00 minimum 5 <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 minim/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ 3 ef( , 00 <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minim/FACILITY) = $234.00 minimum $ <br /> N TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr l $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr I $ <br /> TOTAL DUE S .131, <br /> f1® <br /> FOR OFFICE USE ONLY <br /> Y - - <br /> :::::::• : :: _..........._._...._.........-.._.._...._....�........: • ; .........w .......... _...............-a ....t=::.... :::::::: .................tt:t:ts: <br /> ................................................. ._._._ _ _--- __...................._.._.._.._...._.,_....._ _..-_.....„..... ._..........__., - ... .._.._........._._..:.. <br /> SWEEPS # I COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED ( CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> s <br /> EH 23 032 (REVISED 5-27-97) <br />