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7-24-1998 3-50PM FROM <br />SAN "WIN COUNTY PUBLIC HEALTH SERVICES - EHVIRONMWAL HEAVA DIVSICII <br />UNDERGROUND STORAGE TANK PROGRAM - FEE ILORKSHEET <br />P. 3 <br />S <br />T <br />FAC lL TY SITE NAME <br />FAC L1TY CONTACT NAME <br />-E <br />FACILITY ADDRESS <br />5-44%/ C: <br />TE PHONE # with AREA CODE <br />2-71:51a <br />a <br />A <br />CITY <br />E <br />Z P E <br /># of TANKS <br />at SITE <br />P <br />P <br />APPL�LI�CANT/BR.I,LLLII�NG NAME n <br />APP4 <br />�(�j1NT CONTACT E <br />C <br />N.r}. <br />MAI 7,g. /30 67 <br />ACANT PN # CODE <br />PP 5' <br />T <br />CITY TATE <br />zi E I <br />TYPE of APPLICATION <br />(CLosure, Instatkati on, ate -`i' � <br />nul/ <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure- in•Place) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />$ <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br />$ <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br />$ <br />XXXX <br />XXXX <br />xxxx <br />xxxx <br />XXXX <br />$ Xxxxxxxx <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If AppLicable) <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />xxxx <br />S xxxxxxxx <br />I <br />V <br />TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks = <br />7988 1 <br />7989 <br />1 7990 1 <br />1991 <br />1992 <br />7993 <br />7994 <br />1995 <br />1996 <br />1997 <br />j 7998 <br />F <br />(multiply # by fee for <br />1 <br />A <br />each year applicable) <br />XXX% <br />I xxxx <br />I xxxx <br />t 101X% <br />xX%1( <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />)D= <br />I xxxx <br />I xxxx <br />I XXXX <br />jxxxx <br />I <br />I$ <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 <br />$ <br />T <br />Y <br /># Tanks_ x $8.00 <br />1988 through 1993 ($56) <br />1993 through 1997 (S56) <br />1998 <br />xxxxxxxxxXXXXXXXXXXXXXXX)= <br />XXXXXX)DMXXXXXXXXXXXXx <br />$ <br />SURCHARGE FOR 1998 <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure- in•Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = Sn-00/hour (3 hours minimmITANK) <br /># TANK(S)—CL X $234.00 = $ b <br />5 <br />0 <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />$ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK [.D. #(s) <br />L <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minig"WFACILITY) _ $624.00 minimum <br />$ <br />R <br />REPAIR FEE (Workplan Review & COrStruCtiOn Inspections) TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br />$ <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br />$ <br />M1I TRANSFER FEE _ $20.00 <br />CONSULTATION FEE - 778.00/hr <br />UNAUTHORIZED RELEASE EVALUATION • $78.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />S <br />S <br />TOTAL DUE <br />cu 17 n79 1Vc11Tc 4-11.091 <br />