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SAN JOAOUTA NTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL LTH DIVSION UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET tS FACILITY SITE NAME FACILITY C T NAME 1 T 'E FACILITY ADDRESS SITE PHONE # with AREA CODE e �- CITY LV�TEJ # of TANKS A at SITE \ 2nZDlP P APPLICANT/BILLING AME CANT CT NAME L I C MAILING ADDRS }1 AP ICANT PHONE # WI H/A�REA CODE N TI TATErzj P CODE PPLICAT ION U 01 � 2 (CLos installation, etc.) TOTAL 1986 1487 11988 11989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 A XXXX XXXX I XXXX XXXX XXXX S XXXXXXXX C TFACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX I XXXX xxxx xxxx S xxxxxxxX I V TANK FEE = 550.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1491) E # Tanks = 1988 1989 1990 1991 11992 1993 1994 1995 11996 1 1997 1998 F (multiply # by fee for I i A each year applicable) XXXX XXXX I XXXX XXXX XXXX I 5 I I- C I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX I XXXX XXXX I I I 5 L I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 5 T Y * Tanks x $8.00 1988 through 1993 ($56) 1993 through 1997 ($56) 1998 ' SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXxxxxxxxXX S C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) I TANK I.O. #(s) L 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S P INSTALLATION PLAN CHECK (Plan Review & Construction inspections)I TANK I.D. #(s) L A N PLAN CHECK FEE = 578.00/hour (3 hours minimum/FACILITY) = 5624.00 minimum S R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) E /\ P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 5 DV A I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S R PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = SZ34.00 minimum S M TRANSFER FEE = 520.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S I 1 S C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr S TOTAL DUE 5 3y FOR OFFICE USE ONLY ...................................._........................._....................................._....._...._........_......._.............__._...__...-- ...._..._.................._........:....._.....__. ---- ......................................................................_........................ .........................................._._._...........-.........._........................._.........._................._.--::::::-:.::- _ _==r¢_a__:::s_:_ _::�---..._...^.._............. EIVED SWEEPS # COMPUTER LOC CODE DIST CODE AMOUNT RECEIVED CHECK $/CASH RECEIVED 3Y DATE E 1 .5 - : ............................. _._........................_............ ___.........._._....__......_......__.......�---- ........................:.....:.................................................................................. ......................._.........................................................._....._.._...._....._........................................... _ ................................................._.............................................._.............----...._.._._......._...................._....._......_..............._..................-......_._ :::::: cN Ji n,;? (RFVTSFO 1-12-98)