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SAN JOROUIN COUITT PUBLIC HEALTH SERVICES - ENVIRONMENTAL REAYN OIVSION <br /> 1NIDER00011NtO STORAGE TANK PROGRAM - FEE UORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> PrL u,J <br /> ACILITY ADORES! SITE PHONE IF with AREA CODE,/ <br /> L <br /> GI7T� STATE ZIP CODE a o/ TANKS <br /> A � („f at SITE <br /> v <br /> APPLI T/BILLING NAME APPLICANT CONTACT NAME <br /> M1 3 <br /> C N ILING A KESS APPLICANT PHONE R WITH AREA CODE <br /> 00_7 <br /> A <br /> i CIT7 STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Imtallation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) + $100.00 <br /> A xxxx xxxx xxxx xxxx xxxx S xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx xxxx xxxx xxxx S xxxxxxxx <br /> 1 <br /> V TANK FEE + 1150.00/TANK (Prier to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 1 tanks 1988 1989 1090 1991 1992 1993 1994 1095 1996 1997 1998 <br /> f (multiply a by fae for <br /> A each year applieablq xxxx xxxx xxxx xxxx xxxx S <br /> C <br /> I TANK PENALTY fell ASSESSED xxxx xxxx XXX% I xxxx Ixxx% f <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY•518.50 f <br /> T <br /> I Tanks x 58.00 1988 through 1993 (f56) 1003 through 1997 (556) 1998 <br /> SURCHARGE fOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx I S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-In-Pleee) I TANK I.O. s(s) <br /> L <br /> 0 CLOSURE FEE + 58.00/hour (3 hours minimum/TANK) R TANK(S)_ x 5234.00 + I f <br /> U tg"AAY CLOSURE Well Review i Inspections) TANK I.D. Ilia) <br /> A <br /> E fERPORAAY CLOSURE FEE a 578.00/hour (3 hours minlmn"/FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Platt Review 8 Construction Inspections) TANK I.D. a(s) <br /> L <br /> A <br /> A PLAN CHECK FEE + $78.00/hour (8 hours m(nlmum/FACILITY) • $624.00 mint" S <br /> R REPAIR FEE (Varkp Lan Ravlw L Construction Inspections) TANK I.D. f(s) <br /> E <br /> P tAMK LINING REPAIR FEE a 270.00/hour (3 hours minimum/TANK) R TANK(s) _ x 5234.00 • f <br /> A <br /> I TANK AEtROFIT REPAIR FEE ! $711.00/hour (3 hours min./FACILITY) • $234,00 minimum I S . <br /> R <br /> PIPING REPAIR FEE a !78.00/hour (3 hours minimum/FACILITY) • S234.00 minimum $ <br /> N <br /> TRANSFER FEE + 520.00` UNAUTHORIZED RELEASE EVALUATION - $78.00/hr S <br /> 1 t <br /> S <br /> C I CONSULTATION FEE • 178.00/hr SAMPLING INSPECTION FEE • 578.00/hr f <br /> TOTAL DUE f U17 OO <br /> FCR OFFICE USE ONLY :3159m mmM <br /> 'rlmm.:IRiRIRmmR.!!.! <br /> 1 1 111 ,1 I 1 11 I P II 11 '::iJY111R INRIi '1!II?!I:i:,1111V,iY9".i1 <br /> SVEEPS R COIPUTER a LOC CODE DIST CODE AMOUNT RECEIVED CHECK a/CASH RECEIVED BY DATE RECEIVED <br /> I,IIP1ffi.'RIIIITiII^IR'i'I .111 ,1 ,I �� <br /> ax9anr ,r^•:RT^R!t .. ^.il!RiR! .:R <br /> 'iOmlIS4Rm!IR:m:RrR. I�!m:1.:.9m!m:�:T+m:iMR..R!!11R R 51^::R:IMMIP9;MF,.!R°[4Jm2r.!!ILM1T 10 4!I' d tmna:� J <br />