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SAN JOAGUIN COV, PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE„.,7, DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME ILITY CONT CT NAI�� <br /> T <br /> -E FACILITY ADDRESS SIT PHONE # with AREA CODE <br /> 8- �C\ZS.� ��� G _0 41'A � z l <br /> C STATE P CODDE`—� # of TANKS <br /> A ���,�� ) LV \ at SITE <br /> P <br /> P APPLICANT/BILLIN NAME LICANT CONTACT, A <br /> I <br /> C MAILING ADDRES APPL CANT PHONE # WITH AREA COD <br /> N <br /> T 15zrmTATE IP CODEXP APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 I- 1988 I t989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX I XXXX XXXX XXXX I S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX I XXXX I XXXXXXXX S XXXXXxxx <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1990 1991 11992 1993 1994 1995 1996 11997 1998 <br /> F (multiply # by fee for <br /> Aeach year applicable) Xxxx XXXX XXXX XXXX XXXX I I S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX I XXXX XXXX I I I I ` S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 S <br /> T <br /> Y # Tanks x $8.00 1988 through 1993 ($56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXxxxxXxxxxxxxxxx XXxxxxXXXXXXXXxxxxxxxxX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) it TANKCs) X 5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review $ Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review $ Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum TS <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/haus (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I <br /> S I <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr I S <br /> TOTAL DUE S it <br /> FOR OFFICE USE ONLY ` <br /> _. _._............_.................... -- .._.........._......_._...._..- --•-•.--.........-_...------ ---__—.._._....�------ ------ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> s <br /> cN 7; ni;7 (RFVISF.D 1-12-98) <br />