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SAN JOIIOU IN <br /> PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH DIVISION <br /> AUN OUND STORAGE TANK PROGRAM - FEE WORKSHE <br /> 1 FACILITY SITE NAME d�- Da f S FACILITY CONTACT NAME <br /> T 7 SAM 0K A,-Og (2-D4) 93 -294z <br /> E FACILITY ADDRESS IS-r IS I" �-)ND H(JU Z& SITE PHONE # with AREA CODE <br /> t4M 105 - 1.7 D- 26 43 IOAIE ST. I NDA/E - USF A80VF <br /> CITY y STATE ZIP CODE # of TANKS <br /> A LINDEY� GR 9523(0 I <br /> at SITE 3 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L WAt,-rotJ ETV 6flJft-9JNb I NC. M I KE LEE <br /> C MAILING ADDRESS APPLICANT PH NE # ITH AREA CODE <br /> A Pa &x 1025 ��6 3-71) <br /> T CITY `w �?D STATE ZIP CODE TYPE of APPLICATION IN$Z'ALLf4Tl�yv <br /> ..J� O1"• GPt CIC�g1 (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A %XXX %XXX %%XX XXXX XXXX S XXXXX%XXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX X%%% S XXXXXXXXX%X%X <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E' <br /> # Tanks 3 1986 1987 11988 1989 11990 1991 1992 11993 1994 11995 1997 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX I XXX% XXXX ''10 S5-1 <br /> C)O O <br /> C / <br /> I TANK PENALTY FEES ASSESSEDXXX% %XXX XXX% %XXX XXXX E <br /> L <br /> I STATE SURCHARGE = E 9.00/TANK <br /> T <br /> Y 4j9.6'0/FACILIT( 4 Ig ,ACo <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE = 878.00/hour (3 hours minimum/TANK) I # TANK(s)_ X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P <br /> L INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspections)I TANK I.D. #(s) <br /> / <br /> A 00 <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 mini=on S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S <br /> C� CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S I (0 5 <br /> FOR OFFICE USE ONLY <br /> —. . <br /> SWEEPS # I COMPUTER # I LOC CODE I DIST CODE AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY DATE RECEIVED = <br /> 2. <br /> REVIS D ( 03 ;SQWC 199 • 9 • - --- <br />