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SAM JOAGUIY COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL -EALTH DIVSION <br /> IDERGROUND STORAGE TANK PROGRAM - FEE WORKS <br /> S FACILITY SIT NAME , FACILITY CON ACT NAME <br /> o <br /> E FACILITY ADDRESS SITE PHONE I with AREA CODE <br /> CITYSTATE ZIP CODE I of TANKS <br /> A at SITE <br /> P I � l <br /> LAPPLICANT/BILLING NAME /(� ' I APPLICANT CONTACT NAME <br /> C MAILING ADDRESS /� APPLICANT PHONE � WITH AREA CODE <br /> A C l / <br /> N <br /> T CITY 5 �STATEI ZIP CODE I TYPE of APP <br /> D C{ (Closure, nstallation etc.) <br /> TOTAL <br /> 1986 11987 11988 1989 1990 - <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A XXXX XXXX I XXXX I XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX I XXXX XXXX I XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) I 3170/TANK (After January 1, 1991) oo <br /> E <br /> 4 Tanks = I 1987 1988 1989 1990 1991 1992 I 1993 1994 1995 I 1996 I 199* (y�V +1043 of <br /> F (multiply w oy fee fori I'70 - <br /> A each year applicable) I XXXX XXXX XXXX XXXX (XXXX I I D- 3 <br /> C <br /> I FTANK PENALTY FEES ASSESSED I XXXX I XXXX XXXX XXXX (XXXX I I I I ( S <br /> L, <br /> 11 STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.30 �3 <br /> T <br /> Y 0 Tanks x 58.00 1988 through 1990 (356) 1991 through 1996 (S56) 1997 4,W C 3104 2 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal 'or Authorized Closure-in-Place) I TANK I.D. ;*(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I 4 TANK(s) aX $234.00 = F�d <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.J. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I SZ34.00 minimum 3 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. ;*(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum s G <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. ;*(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) 9 TANK(s) X 3234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimums 3 <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> H TRANSFER FEE = S20.00 ( I UNAUTHORIZED RELEASE EVALUATION = 378.00/hr I I S <br /> I I I <br /> S <br /> C CONSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION FEE = S78.00/hr I I 3 <br /> TOTAL DUE saw <br /> FOR OFFICE USE ONLY <br /> SWEEPS COMPUTER 9 I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK 2/CASH I RECEIVED 3Y DATE RECEIVED <br /> � 3 <br /> EH 23 032 (REVISED 5-27-97) <br />