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It SAN J@1OUIN COIALIC HEALTH SERVICES - ENVIRONMENTAL NEALTOVSION <br />,... crrous TAMV WWWAM - FEE WORKSHEET <br />5 <br />FACILITY SITE NAME I <br />1986 11987 11988 11989 <br />%%X)t I XXX% I %XXX XXXX <br />FACILITY CONTACT AME <br />�� LAI- <br />I <br />S XXXX%XXX <br />C <br />TFACILITY <br />PENALTY FEES ASSESSED (If Applicable) <br />T <br />"E <br />FACILITY ADDRESS <br />5 F PHONE * with cn AREA CWE^'� <br />7,0 C-7 <br />',YIF-• y `-�`� <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) I <br />5170/TANK CAfter January 1, <br />1991) ' <br />!!!1 �+' <br />3 <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />at SITE <br />P` <br />n <br />! %XXX XXXX ( XXXX <br />X%%X I%%XX I I <br />P <br />APPLICANT/BILLING NAME <br />— <br />TANK PENALTY FEES ASSESSED XXXX XXXX ( %XXX <br />APPLICANT CONTACT NAME <br />LY <br />+ <br />I S <br />L <br />I <br />C <br />A <br />MAILING ADDRESS I \ <br />APPLI CANT PHONE 'J ITN AREA r_XE <br />N <br />TI <br />CITY <br />STATE ZIP CODE I TYPE of APPLICATION <br />II1 /�(Closure, Installation, etc.) <br />1993 through 1997 (556) <br />%X%XXXXXX%X%%%%XXXXXX%X <br />'998 <br />TnTAI <br />A <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />1986 11987 11988 11989 <br />%%X)t I XXX% I %XXX XXXX <br />1990 <br />XX%X <br />S XXXX%XXX <br />C <br />TFACILITY <br />PENALTY FEES ASSESSED (If Applicable) <br />I XXXX I %XX% %XXX XXXX <br />! X%XX <br />S XX%%X%XX <br />I <br />V <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) I <br />5170/TANK CAfter January 1, <br />1991) ' <br />E <br />F <br />A <br />9 Tanks <br />(multiply # by fee for <br />each year applicable) <br />1 1988 11989 1990 11991 <br />11992 11993 <br />1994 i 1995 11996 1997 <br />1998 <br />! %XXX XXXX ( XXXX <br />X%%X I%%XX I I <br />S <br />Cr <br />I <br />— <br />TANK PENALTY FEES ASSESSED XXXX XXXX ( %XXX <br />I XXXX (XXXX <br />I I I <br />+ <br />I S <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=S18.50 <br />' S <br />T <br />Y <br /># Tanks_ X 58.00 1988 through 1993 (556) <br />SURCHARGE FCR 1998 XXX%XX%XX%XX%X%%%%%%%%%XX%X a <br />1993 through 1997 (556) <br />%X%XXXXXX%X%%%%XXXXXX%X <br />'998 <br />I S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) <br />TANK 1.0. #(s) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) IiANK(s)_ <br />5 X 5234.00 = <br />+ S <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review 3 Inspections) <br />TANK I.D. #(a) <br />R <br />E <br />TEMPORARY CLOSURE FEE - 578-00/hour (3 hours minimum/FACILITY) I <br />5234.00 minimus <br />{ ; <br />P <br />INSTALLATION PLAN CNECK (Plan Review & Construction trapections)I <br />TANK I.O. #(s) <br />L <br />A5 <br />N <br />PLAN CHECK FEE = S78.00/hwr (8 hours minimum/FACILITY)= <br />5624.00 .minimm <br />f <br />R <br />REPAIR FEE (Workplan Review S Construction Inspections) <br />j TANK I.O. I(s) <br />E1P <br />TANK 'LINING REPAIR FEE = S78.00/hour (3 hours minims /TANK) <br />I TANK(S) _ X 5234.00 = <br /># <br />5 <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= S234.00 mini mui;i <br />S <br />R <br />PIPING REPAIR FEE S73.00/hour (3 hours minimm/FACILITY) <br />= 5234.00 minimum <br />S <br />M <br />TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I <br />I S <br />I <br />� <br />i <br />1 <br />S <br />Ci <br />CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE <br />= 578.00/hr <br />, S <br />FOR OFFICE <br />TOTAL DUE S <br />SWEEPS 4 COMPUTER # LOC CODE I DIST CSE #/ <br />AMOUNT RECEIVED CNECK CASH RECEIVED dY GATE RECEIVED <br />94 7i 117 lRFVT5F0 1-12-98) <br />