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j <br /> SAN dOAgUIN COUNTY 'PUBLIC HEALTH SERVICES - ENVIRONMENTAL HFJI.TH5LON <br /> ' UNDERGROUND STORAGE TANK PROGRJLM - FEE WaORiSHEET <br /> 5 FAC ITVS ENA FACILITY CONTACT NAME <br /> -} .' GSC r� L,T <br /> T <br /> I 'E FACILITY ADDRESS 5 TE PHIS 9 with AREA CODE <br /> CIT � STATE FP CODE w af'TANKS <br /> I A * 5 at SITE <br /> i P 159/5 <br /> P1 APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Lfel <br /> I <br /> C MAILING- ADDRESS a APPLICANT ?HC P 9 WITH ]RSA C9DE <br /> N <br /> T CITY STATE ZIP CODE STYPE of APP[tICATION S�r <br /> E <br /> ft <br /> � �� ;,(Closure,,-Installation, etc.) <br /> i+ TOTAL <br /> y <br /> 198611 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100,00 <br /> A XXXX i I xxxx I xxxx I xxxx I xxxx I S xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXXI; xxxx -1 XXXx I xxxx I xxxx $ xxxxxxxx <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) I S170/TANK II (After ,January 1, 1991) <br /> E <br /> I Tanks = 1988 1989 11990 1991 11992 1993 199411 1995 +I 1996 11997 11998 <br /> F (multiply by fee for <br /> A each year applicable) I XXXX xxxx I xxxx I XXXX xxxx ILi I S , <br /> !! } <br /> E TANK PENALTY FEES ASSESSED I XXXX XXXX I XXXX I XX%X IXXXX I I �!I I I I $ � <br /> L i <br /> I STATE SURCHARGE FOR NEN FACILITIES ONLY=$18.50 i $ <br /> T <br /> Y M Tanks x $8.00 1988 through 1993 ($56) 1993 through 1997 (356) 1998 1 <br /> 'Y <br /> SURCHARGE FOR 1998 I XxxxxxxXxxXxxxxxxxxxxxXxxxx x%xxxxxxxXXXxxxxxxxxxxx S <br /> L <br /> i� <br /> CPE RMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK 1.0. x(s) <br /> L <br /> 01 CLOSURE FEE = S78.G0/hour (3 hours minimums/TANK) I B TANK(s)lj- X S234.00 = T. � ry <br /> S. <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. ;�(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 378.00/hour (3 hours minimum/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Pian Review $ Constructions Inspections)I TANK I.D. i(s) c <br /> i L <br /> A <br /> E N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00I minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. JY(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) I X 5234.00 = $ <br /> A <br /> I TANK RETROFIT_.'.REPAIR"FEE";= $78.00/hour (3 hours min./FACILITY) = $234.001 minimum S. <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/,FACILITY) = $234.00 minimum S <br /> a <br /> M TRANSFER FEC = $20.00 j UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I S <br /> S 3 <br /> C CONSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION FEE = $78.00/hr S <br /> TOTAL DUE $ r.23%-00 <br /> ,Op <br /> FOR OFFICE_US_E_ONLY __ _ _ ---_-_- <br /> ........_.. .... ..... .... .._.. ... _ <br /> ...............::......_::...................:::..:......._.::..::::::..:..:r::..:::....::: ..... ... <br /> .........».r._......_....._....._..._�_._:..z::r.:c::_::_:__..�.._..__:� _:c • :::r.:::::�:_r___.:_::_:—�._��:.a_'•' .��—_—r_:':E=_:E_.2:�_ <br /> SWEEPS 9 COMPUTER 9 LOC CODE DIST CODE AMOUNT RECEIVED CHECK ASH I RECEIVED SY I DATE RECEIVED <br /> :/C <br /> S <br /> -1-- --�- - - - <br /> Gu 71 n-;? rREvrsED 1-12-98) l <br />