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SO JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSI011 <br /> UNDEUIRM O STORAGE TANK PROGRAM - FEE WRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> C - - , <br /> LA� TY ADDRESS SITE q — S-with I�REJ1 C00�4 �5, — <br /> CITY �3 STATE ZIP CODE 0 of TANKS C��/ <br /> A ^�7 at SITE <br /> P L <br /> P APPIICA /BILLING NAME APPLICANT CONTACT NAME <br /> C LING AWNWS APPLICANT PHONE N WITH AREA CODE <br /> A <br /> A <br /> � <br /> Til CI Y STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 11 1991) $100.00 <br /> Al xxxx xxxx xxxx xxxx xxxx S xxxxxxxx <br /> c <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx xxxx xxxx xxxx z xxxxxxxx <br /> I <br /> V TANK FEE 1150.00/1'ANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> f Tanks 1988 1989 1990 1 1991 1992 1993 1994 1995 1996 11997 1998 <br /> F (multiply 0 by fee for <br /> A each year spplleable) xxxx XXXX XXXX xxxx xxxx s <br /> C <br /> TANK PENALTY FEE! ASSESSED xxxx xxxx xxxx xxxx (xxxx s <br /> L <br /> STATE SURCHARGE FOR NEW FACILITIES ONLY418.50 S <br /> T <br /> I Tanks x $5.00 1988 through 1993 (556) 1993 through 1997 (556) 1998 <br /> i <br /> ?SURCHARGE FOR 1998 xxxxxxxxxxxxxxxXXXXXXXXXXXx XXXXXXXXXXXXXXXXXXXXXXX S <br /> cj PERMANENT CLOSURE (Removal or Authorized Closure-in-Plece) TANK I.D. x(s) <br /> L <br /> 0 CLOSURE FEE a $78.00/hour (3 hours minim m/TANK) 0 TANK(s) x S234.00 = I S <br /> S <br /> U TEMPORARY CLOSURE (PISA RSview i Inspections) TANK I.D. S(s) <br /> R <br /> E TEMPORARY CLMURE FEE a !78.00/hour (3 hours miniM m/FACILITY) 1234.00 minimus s <br /> P INSTALLATION PLAN CHECK (Plert Review i Conatructlon Inspections) TANK I.D. 0(s) <br /> L <br /> A <br /> M PLUM CHECK PEE a 1178.00/hour (8 hours alnlmLm/FACILITY) ■ S624.00 minimus S <br /> R REPAIR FEE (WOrkplan Wilaw i Corstruction Inspections) TANK 1.0. R(s) <br /> E <br /> P 1ARK LININO REPAIR FEE a 17S.00/hour (3 hours minimum/TANK) 0 TANK(s) X $234.00 • S <br /> A n <br /> I TAxK RETROFIT REPAIR FEE a $78.00/hour (3 hours min./FACILITY J:,stkv;m minimtm <br /> R <br /> PIPING REPAIR FEE a 278.00/hour (3 hours minimum/FACILITY) 5234.00 miniasun S <br /> R TRANSFER FEE a !20.00 UNAUTHORIZED RELEASE EVALUATION s SM OO/hr S <br /> s <br /> C cOHSULTATION FEE s 578.00/hr SAMPLING INSPECTION FEE s 178.00/hr S �7 <br /> TOTAL DUE S <br /> FCR OFFICE USE ONLY <br /> I II u'I N III 1111'IIVIRIWNIIi 1 II R I!II AI!RiN11G[�li IIUI RIR!!il lir a'!'ll'!I.'. <br /> MSPS a COMPUTER R LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASH RECEIVED 8Y DATE RECEIVED <br /> S rnRu!aelrtl!ar !a�c �^e�mn gmar+ rm^^ <br /> , r:.� .o:R^ .i! .R RR!HI!RR?IF.!W!. R'RI:I^!'�'.PRI!L'.T.7g};�:RliRR!!RR'i?t!IIIR!!'iI�''iii iiigRlii gilF MR <br /> 'i�:l <br /> !x 23 032 (REVISED 1.12-98) <br />