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SAM JOAOUIN COUP—• PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAL" DIVSION <br /> UKp am STORAGE TANK PROGRAM - FEE WORKSHEET <br /> �1/ I <br /> 5 FACILITY TACT NAME <br /> FACILITY SITE NAME <br /> T Gsh�U <br /> 'E FACILITY ADDRESS i SITE PHO d with AREA CCOE <br /> D S • ,J o 9 FOA �,2.50 <br /> a 14 I STATEI ZIP CODE at TANKS <br /> CITY 5-p I at Si TE <br /> Ate/f)I <br /> P i APPLICA#T CONTACT NAME <br /> P APPLICANT/BILLING NAMEp` ' y <br /> L �1 C <br /> I APPLICANT PHONE : WITH AREA CODE <br /> C LNG ADDRESS <br /> A cl/� 0 "?� .�i7J 1 <br /> CITY ATE ZIP CODE PLICATION <br /> T <br /> I �iJn/ (Closure, nstallation, etc.) <br /> SCJ OV TOTAL <br /> 1986 11987 11988 1989 11990 <br /> ANNUAL FACILITY FEE (Prior :0 January 1, 1991) = 5100.00 I XXXX %XXX I %XXX I XXXX S XXXXXXX% <br /> A <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> %XXX XXXX %XXX x00( XXXX S XXXXXXXX <br /> II 5170/TANK (After January 11 1991) <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) <br /> E <br /> N tanks = 1988 11989 11990 11997 11992 11993 11990 11995 11996 11997 11998 <br /> A eacht <br /> tyear applicahle)r I %XXX I XXXX I XXXX I %XXX l%XXX I I I I I S <br /> C <br /> I TANK PENALTY FEES ASS'ESS'ED I XXXX I XXXX I XX%X I %XXX XXXX I I I I ( S <br /> L S <br /> I STATE SURCHARGE FOR NE'A FACILITIES ONLY=518.50 <br /> T ,T 9 Tanks_ z 38.00 1988 through 1993 ($56) 1993 thraugn 1997 (556) 1998 <br /> SURCHARGE FOR 1998 I XXXXXXXXXXXXXX%XXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX I I S <br /> C PERMANENT CLOSURE (Removal or AUrhori ed Ctasure-in-P(ace) TANK I.D. :(s) <br /> LI : TANK(s) X 3'234.00 = S <br /> OI CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> S TANK I.D. 3(s) <br /> U TEMPORARY CLOSURE (Plan Review 3 Irtpec:Tort) <br /> R 373 S <br /> E TEMPORARY CLOSURE FEE = S78-00/hour (3 hours minimm/FACILITY) I 4.00 minimum <br /> PI INSTALLATION PLAN CHECK (Plan Review d Construction Inspe'-ti0ns)I TANK E.O. +(s) <br /> L <br /> A 5624.00 mini mum <br /> S <br /> N PLAN CHECK FEE - 378.00/hour (8 hours minimum/FACILITY) <br /> Rj REPAIR FEE (Workp(an Review 3 Construction Inspections) TANK 1.0. 1(s) <br /> E S <br /> PI TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) N TANK(s) _ X 5234.00 = <br /> A ' S <br /> TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILM) = S234.00 minimum <br /> R I <br /> PIPING REPAIR FEE = 378.00/hour (3 hours minimum/FACILlTY) = 5234.00 minimum S <br /> MI TRANSFER FEE = 520.00 I I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I I S <br /> S S <br /> C CONSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION FEE = 378.00/hr <br /> TOTAL DUE ( 5 /I G p6 <br /> FOR OFFICE USE ONLY <br /> SWE=PS 2 COMPUTER A LCC qC�E I DIST CODE AMOUNT RECEIVED CHEC */CASH p.9Ei=tVED BY DATE RECE IVEO <br /> Ja I! <br /> 79 <br /> EH 23 032 (REVISED 1-12-98) v` -( <br />