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SAN "QUIMPUBLIC HEALTH SERVICES - ENVIRONMENTAL H�/I OIYSION <br /> GROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME `� FACILITYt4_7 <br /> /JC7 NAME <br /> I �fi <br /> T <br /> 'E FACILITY ADDRESS _/J SITE PHONEa 'th AREA CODE <br /> Al CITY STATE ZIP CODE� 9 of TANKS <br /> / /x-N L.!"� C at SITE ` -��SS <br /> P <br /> PAPPLICANT/BILLING NAME APPLICANT L TAC N E <br /> teI <br /> C MAILING ADDRESS APPLICANT PHONE R WITH AREA CODE <br /> w /� Q✓e-re �r ID i 3'32 - 2Yio a! <br /> TI CITY ,�i /nJ,,11 STATE ZIP CODE TYPE of APPLICATION <br /> ,'Gpt-Cij �� 9,537�n (Closure, Installation, etc.) <br /> TOTAL <br /> 11986 1987 1988 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A xxxx xxxx j xxxx Xxxx I xxxx 5 xxxxxxxx <br /> C' <br /> T. FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX XXXX j XXXX xxxx XXXX S %%%XXXX% <br /> I <br /> VF TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E, <br /> F %multiply Tanby fee for 11988 1989 1990 11991 1992 1993 1994 1995 7996 11997 11998 <br /> A each year applicable) XXXX I XXxX I XXXX I xxxx Ixxxx I I n �� Ift l b �l b yl t 5 Q <br /> I TANK PENALTY FEES ASSESSED I XXXX I XXXX I XXXX I %XXX Ixxxx I �� p I I p O 5 U <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY--S!8.505 <br /> T <br /> Y S Tanks x 58.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXxxxxxxXxxxxxxxxxxx S <br /> L PERMANENT CLOSURE (Removal or Authorized Ctosure-in-PLace) TANK [.D. :(s) Tee- <br /> 1 O S (l <br /> 93�0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I TANK(5) % 3234.00 = S <br /> S <br /> Ul TEMPORARY CLOSURE (Plan .Review 8 Inspections) TANK L0. :(s) 4e&l <br /> R 5 ^fly <br /> EI TEMPORARY CLOSURE FEE 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum (/ <br /> PI INSTALLATION PLAN CHECK (PLan Review 3 Construction Inspections)I TANK 1.0. +(s) J <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> RI REPAIR FEE (Workplan Review 3 Construction Inspections) TANK [.D. -(S) <br /> E <br /> PI TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I X TANK(s) _ X SZ34.00 = S <br /> A <br /> II TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> MI TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> Cl CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> i3 SWEEPS x COMPUTER x I LOC CODE GIST CODE AMOUNT RECEIVED CHECK d/CASH RECEIVED BY GATE RECEIVED <br /> EH 23 032 (REVISED 1-12-98) <br />