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SAM JOA* COUNTY PUBLIC HEALTH SERVICES - ENVIROMMESEALTH DIVSIOM <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T 0 00 1, 2 <br /> "E FACILITY ADDRESS / SITE PHONE Al with AREA CODE <br /> & 2`e5 `co s o D 2oQ - 4b2-- 27y� <br /> CITY �/ /STATE 21P CODE X of TANKS <br /> A S t�Ocie 52o at SITE a <br /> P <br /> P APPLICANT/BILLING NAME At LI CANT CO TACT NAME <br /> on FRE f G7�" (r <br /> C MAILING ADDRESSnn APPLICANT PHONE Y WITH AREA CODE <br /> A -1 W�.S a 71vEL'Q9- -79V-V7z <br /> T CITY r STATE 2)P CODE TYPE of APPLICATION <br /> InstaLLation, etc.) <br /> TOTAL <br /> 1 1 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = Si00.00 1986 1987 1988 1989 1990 <br /> A xxxx I %%x% I xXxx I X%Xx I XXXX S XX XXxxx <br /> C <br /> 7 FACILITY PENALTY FEES ASSESSED (If Applicable) I xxxx I %XXX xxxx I %%xX %XXX S %X %XXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E <br /> Tanks = 1988 1989 1990 119911992 11993 11994 1995 1996 1997 i 1998 <br /> F (multiply X by fee for <br /> A each year applicable) %Xxx I XXXX I XXXX %x%x Ixxxx I I I S <br /> Il l i <br /> I TANK PENALTY FEES ASSESSED %XX% XXXX X%%X I xxx% lxxxx i l l g <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.30 ( 5 <br /> T <br /> Y d Tanks_ x 58.00 1988 through 1993 (456) 7993 through 1997 (456) 1998 <br /> SURCHARGE FOR 1998 I xxxxxxxxxxx%xxxxxxXxx%%XXXX I xxxxxxxxxxxxx%XXX%X%xxx ' S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) ITANK I.D. =(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I i TANK(S) <br /> % 5234.00 = 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. �(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimuNFACILITY) I 5234.00 minimum 5 <br /> PI INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.O. +(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624-00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. :(s) <br /> E I <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimaa/TANK) I X TANK(s) X 5234.00 = I S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234-00 minimum S <br /> M TRANSFER FEE = S20-00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr I I SAMPLING INSPECTION FEE = 578.00/hr I S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> !__- . <br /> SWEEPS S I COMPUTER x I LOC CODE I DIST CODE] AMOUNT RECEIVED I CHECK O/CASH I RECEIVED BY I DATE REC'c IV D <br /> S <br /> ..: <br /> __ I <br /> : <br /> EH 23 032 (REVISED 1-12-98) <br />