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SAI) JOAOUIN COUNTY PUNLIC REALTN SERVICES EAVIRONNENTAL HEALTH DIVSION ,'•',rt UNDEkCROUND STORAGE TANK PROGRAM - FEE WORKSHEET S FACILITY SITE NAME FACILITY CON CT NAME i TM.6: I: E FACILITY ADDRESS SITE PHONE # with AREA CODE STATE ZIP CODE # of TANKS CITY c7 at SITE j A 5' 7 Y• P APPLICANT/BILLING NAME APPLICANT CONTACT NAME L T2 1 C MAILING ADDRESS APPLICANT PHONE# WITH AREA CODE i N 1 rCITY STAT> ZIP CODE TZ APPLICATION ur Installation, etc.) TOTAL =�3 1986 1987 1988 1989 1990 ANNUAL FACILITY FEE (Prior to Janu6ry 1, 4991) !100.00 1 A xxxx xxxx xxxx xxxx xxxx S xxxxxxxx C T FACILITY PENALTY FEES ASSESSED (If Applicable} xxxx xxxx xxxx xxxx xxxx' ! xxxxxxxx l i V TANK FEE 150.00/TANK (Prior to January 1,1991) 170/7ANK (After January 1, 1991 $)��id CAie�,n 'Fcr` E N Tank§ = 1987 1988 1989 1990 1991 1992 1993 1994 1995 J119961997 tQ��'.i�f•. T ti,� F (multiply # by fee for Ceach year applicable) xxxx xxxx xxxx xxxx xxxiso- I`!a' Ili- o- 1 D ` ' I TANK PENALTY FEES ASSES5E0 xxxx xxxx xxxx xxxx xxxx S n L 11 SSCP ' I STATE SURCHARGE FOR NEW FACILITIES ONLY = 918.50 E! T f! Tanks x $8.00 MIS through 1990 (!56) 1991 through 1996 (S56) 1997j) SURC#ARGE FOR 1997 xxxxxxxxxxxxxx%xxxxxxxxxxxx xxxxxxxxx%%xxxxxx%xxx%x C PERMANENT CLOSURE (Removal or'Authorited Closure-In-place) TANK 1.0. !f(s) 'fi,� '}'• L 4i 0 CLOSURE FEE = !78.00/hour 0 hours minimum/TANK) 0 TANKW- _ x !x34.00 ?, 1, 5 S r U TEMPORARY CLOSURE (Plan 9#06W I Ihspections) TANK I.D. #(s) E 1EMPORARY CLOSURE FEE n !78.00/hour (3 hours minimum/FACILITY) !234.00 minimum S P INSTALLATION PLAN CNECK (plan Revlon & Construction inspections) TANK I.D. CO.) L y } N PLAN CHECK FEE _ !78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum ! R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE ! $78.00/hour (3 hours minimum/TANK) M TANK(s) x $234.00 s S A ; I TANK RETROFIT REPAIR FEE s 178.00/hour 0 hours min./FACILITY) = 5234.00 minimum S R PIPING REPAIR FEE • !78.00/hour 0 hours minimum/FACILITY) ■ $234.00 minimum ! `•; at�� • I+r N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION 578.00/hr S *; l S •<`i C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE _ 978.'00/hr !' ` TOTAL DUE S a; FOR OFFICE USE ONLY ..�.;; I!I!I!!!II!IIII!II!!!!!!1111!lrrrr!t!gl!!I!!!!116!!!tl!1!!I!I!111111!!!!!!IIIII!il!IIII!Illmlllllll!!Uli! r I II B!!!!11f1!!I!It!!!I!!!I!I!!!rE=!?!!I!3!{ 1![!!!!!I!!!p!mrgii t sm ru rl r I:r s s s i.•r 4: { : i :e i n I:r rr :u i uu»nu!r rr n e=: •:!n :mr:vlu:nur tts! r 'fi I, I I 1 !!!.l1n IIIII IIIII ryry I L!....11...Ii..ILILL.Li.l.il..ir.!!!.13!!.IIIL III IId1!!.!.i.11..11ll.l.!3..!{I!.!..I,L.,.},,,....LL.r..l.!!..Ni..i.,IIL....{............IIIf....11.�i!!m .•. .. ui ^r..r :•:::: : : �r:^• r•:u•r�n r•::n :r.i r i :: ,li rr:...:r:r•rr•r?: :: :rrm• .. r;: :•a i.. ,r.,.U.:-.:..:-rl li...:.-.-IhiI,:l6i.1.1.IIIIIIII i.1.1.lllll,rl!ILFF-1!l:lllllllil.i.IIIc LILi.,l.u,-..:-n...u. ,,,:!.,.UIIInU{-:Iti..r.Fr,Hlllf!!!1111611l1l6i!iillii!ii!IfMiTiffiiilii!Iiliil!i!!!!I!!Ilill!H!f:!:udi4?{il!Iiiiilii!!i!Iiiil!Ili!i!!i>!F{!HIIIii!iffi{ii!!!!liii!illi!ilfiFfilli!IffFFFI��'' SWEEPS ! COMPUTER # LOC CODE i GIST CODE AMOUNT RECEIVED CHECK N/CASH RECEIVED BY DATE RECEIVED flf `i` fel .::..........:.:.........: :.:.:.......:.::::::.Eiii!::ne� . : ....... . :.r.......1.......arz: ...t......t.......... .....r ....:...$ ..r...............,..................... i.!......t..................u..n..:....e.s..r.e...o.......................r..:...............,... . .:.u.=.............:...... : .i....... ... u.:.:..........r!r... Lr .Lr.. ..:.a..:........m...Ir.e....:......v...........r...-i........:......i.......:i-........:.... ..,............L....s<::a:...:.•i.!s.i.s.:i....,..•...... cu .....,.........,..:......:.:ul!.:.:.r?.:.,{r':rE,lI :F�iii!!!Fiivfei9!!iiriu{{{