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SAN JCACUIN CCUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNOERGRGUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CCWT NAME <br /> T �`f J <br /> 'E FACILITY ADDRESS SITE PHONE with AREA CCOE <br /> C.2�) a82- 78 <br /> CITY STATE ZIP CODE 9 of TANKS <br /> AL...l.A��OP C�- C1533o at SITEP $ <br /> ?I :'?LICANT/8tLLING NAME APPLICANT =11TACT HAkE <br /> I r <br /> C� -AILING ADDRESS APPLICANT PHONE A WITH AREA CCOE <br /> A C�9�F_/� � l (7C)-7) A410— <br /> u;.5 <br /> N <br /> T�CITY STATE ZIP CODE TYPE of APPLICATION 8 <br /> V14VM,,F I �' S"�8� (Closure, Instatlation, etc. .Gtp`aI,(Rt. <br /> TOTAL <br /> I1986 11987 1 1988 � 1489 11990 At;NU FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> AI XXXX 1 XXXX XXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Appticable) XXXX I XXXX 1 XXXX 1 XXXX 1 XXXX $ XXXXXXXX <br /> I <br /> V '*-,NK FEE = S50.00/TANK (Prior to January 1,1991) 1 5170/TANK (After January 1, 1991) <br /> E <br /> Tanks = 1988 1 1989 1 1990 1 1991 1 1992 1993 i 1994 1995 1 1996 1 1997 11998 <br /> F (muttipty 0 by fee for <br /> A each year applicable) XXXX 1 XXXX I XXXX I XXXX (XXXX I S <br /> I I I I I -e- <br /> II XXXX I XXXX iXXXX I S <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 S <br /> T <br /> Y d Tank;i.. x 58.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXxxxxax S <br /> C' ::RMANENT CLOSURE (Removal or Authorized Ctosure-in-P(ace) TANK I.D. X(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours miniaun/TANK) 9 TANK(s)�_ X 5734.00 = S <br /> 5 <br /> U TEMPORARY CLOSURE (Ptah Review & Inspections) I TANK I.D. it(s) 39 Z0. <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILIT7) 5234.00 minimum S .�-- <br /> P INSTALLATION PLAN CHECK (Pian Review b Construction Inspections) TANK I.D. 9(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 2624.00 minimum S <br /> R REPAIR FEE (Workp(an Review b Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) 0 TANK(s) X 5234.00 = S - <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S .. <br /> K TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr i S e <br /> I <br /> S <br /> CONSULTATION FEE = S78.00/hr 1 I SAMPLING INSPECTION FEE = S78.00/hr 1 1 S <br /> TOTAL DIRE 5 <br /> FFICc USE CULT 0 c <br /> - t e ««ia <br /> _......___...._..---_....:»:.tea.,»»_..»» _..�......_.»»...__...._-....._«.;.r......t•'....�___.._........._..«._.....».._...._.._--_._.._..._._._.._...._...�.__._...__.«.__.:.'=_:a:::.••::-::----�--....�.�......_.M__._....« <br /> SWEEPS 0 COMPUTER 9 I LOC CODE DIST CODE I AMOUNT RECEIVED I CHECK x/CASH RECEIVED BY OATE RECEIVED , <br /> R7r*n++n.�FiP.^.!!'S!:.:....^.^.!!�ina. _. °'!!?: rrm*:::_ <br /> 123 032 (REVISED 1-12-98) <br />