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S-26-1998 1 :d8Ph1 FROM P, d <br /> SAM JOAQUIN COUNT, .-LIC W-ALT14 SERVICES - ENVIRONMENTAL HEALTH D►.sION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SFACILITY SITE NAME n FACILITY CONTACT NAME <br /> E4 FACILITY ADDRESS SITE NONE 9 Lith AREA CODE <br /> CITY STATES TIP CODE f of TANKS <br /> PC�� ai SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> C MAILING ADDRESS APPLICANT PHONE $ WITH AREA CODE <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> SC� 1 SC] C CIS% )a (Closure, IRStaitation, etC.) <br /> TOTAL <br /> 1986 ` 1987 11984 1989 1990 � <br /> ANNUAL FACILITY FEE (Prior to :arxJary 1, 1991) = S100.00 <br /> A XXXX )OM ± XXXX f XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If ApptiCab(t) ' XXXX ( XXXX X)= XXXX XXXX S XXXXXXXX <br /> 1 <br /> V1 TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> I Tanks = 1987 1988 S 1989 ( 1990 1991 1992 f 7993 1994 1995 f 1996 1997 <br /> F (mu(tip(y Y by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX <br /> C <br /> I� TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX lxXXX <br /> i <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLT * $18.50 is <br /> T <br /> Y x Tanks x 58.00 1988 through 1990 ($56) 1991 through 1996 (S56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXX700(XXXXXXXXXXXXXX0XX XXXXX)QOOIXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Plate) ` TANK I.D. $(s) <br /> l <br /> 0 CLOSURE FEE - $78.00/hour (3 hours minim—/TANK) # TANK(s) X sn4.0O = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I_D. #(S) <br /> R <br /> E TEMPORARY CLOSURE FEE _ %78.001hour (3 hours mininAW FACILITY) (236.00 minia. S <br /> P INSTALLATION PIAN CHECK (Plan Review Z Construction Inspections) TANK I.D. x(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours miniaaW FACILITY) $624.00 mini mup TS <br /> R REPAIR FEE (Workplan Review i Construction Inspections) TANK I.O. 0(s) <br /> E <br /> P TANK LINING REPAIR FEE = 178.00/hour (3 hours minin WTANK) 0 TANK(s) X 5234-00 = S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) - SM.00 Minimum $ <br /> R <br /> PIPING REPAIR FEE s %78.00/hour (3 hours minimun/FACILITY) 5234.00 minimus S <br /> N TRANSFER FEE = $20.00 UNAUTHM I7.FD RELEASE EVALUATION = S78.00/hr +1na - Y' <br /> I I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr i S <br /> TOTAL DUE s <br /> FOR OFFICE USE ONLY <br /> SUEEPS Y ! COMPUTER N LOC COOS DIST CODE AMOUNT RECEIVED CHECK iI/CASE RECEIVED BY I DATE RECEIVED -� <br /> 1 <br /> I S � <br /> N.L7'L'>!111. _ hlClriu: -"1L•N1t11�^ Jrl{{rr ":_:Ili..—n.n'EN..:'DTII VL m-_..T— .M L <br /> ..Illi.ir.. Jt'F'll i .. 11',0{1111�:xIIkI:'1... .U1G .L;,....�.._..,.. .14-i.,.. ..�'ib4.:.i�:a{::.1 •.u....___—..__�I...n.,._. �._� {. <br /> w.+- <br />