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. . 10 1N COUINTY PUBLIC HEALTH SERVICES - ENV1 NTAL HEALTH 01VSION <br /> UNDEROMM STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY C ACT NAME <br /> PF�VA A 41?-Z IF <br /> .ACILITY ADDRESS SITE PHONE N with AREA CODE <br /> 3 ?( 3c{13 <br /> CITY SPATE ZIP CODE N of TANKS <br /> A _ \ �(�� at SITE <br /> P C/� �V <br /> APPLICANT BILLING NAME / APPLICANT CONTACT�'ME <br /> C ILING AKESS APPLICANT PHONE NN WITHHJ AREA CODE <br /> A c_ M),-- - Z q(21 U - <br /> TI CITY STATE ZIP CODE TYPE of APPLICATION <br /> -�,c.,rc .� (Closure, Installation, etc.) <br /> c TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) ' $100.00 <br /> A xxxx xxxx xxxx xxxx xxxx s xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Appticebte) xxxx xxxx xxxx xxxx xxxx S xxxxxxxx <br /> I <br /> y TANK FEE 550.00/TANK (prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> A Tanks = 1988 1989 1990 1991 1992 1 1993 1994 1995 1996 1497 1998 <br /> F (mulclPty N by fee for <br /> A each year apptlesbte) xxxx xxxx xxxx xxxx xxxx 5 <br /> CI TANK PENALTY FEES ASSEISEO xxxx xxxx xxxx xxxx (xxxx S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=!18.50 S <br /> T <br /> I tanks x MOD 1988 through 1993 (f16) 1993 through 1997 (556) 1998 <br /> ?SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxx XXXXXXXXXXXXXXXXXXXXXXX 1 s <br /> cl PERMANENT CLOSURE (R of or Authorized Closure-in-Place) TANK I.O. N(s) <br /> L' <br /> 0 CLOSURE FEE a 178.00/hour (3 hours minimum/TANK) N TANK(s) X S234.00 = I L <br /> s <br /> U T A>tY CL E (P(SA Revfew t Inspectfons) TANK I.D. S(s) <br /> R <br /> E <br /> ffpNAAy Ct E PEE • 178.00/how (3 hours miniesm/FACILITY) 5234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (PISA Review 8 Construction Inspections) TANK I.D. N(s) <br /> L- <br /> A <br /> M PLAN CHECK PEE a 578.00/how (8 hairs minimum/FACILITY) = $624.00 minimae S <br /> RF-REPAIR FEE (Morkplan Riview i Construction Inspections) TANK I.D. 40) <br /> E <br /> P TANK LINtNG REPAIR FEE ® 178.00/hair (3 hours minimum/TANK) N 1ANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE a 578.00/hour (3 hours min./FACILITY) v $234.00 minimum <br /> Is <br /> Z&17."m <br /> R <br /> PIPING REPAIR FEE a 578.00/Maur (3 hours minimum/FACILITY) ' S234.00 minimus S <br /> N TRANSFER FEE • 120.00` UNAUTHORIZED RELEASE EVALUATION • S7800/hr S <br /> I i <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S Z 6 e41 <br /> F(l OFFICE USE ONLY <br /> mmr�tm <br /> n i! armnm.uucu;is�r�a�.!:,nus�� <br /> SWEEPS s COMPUTER N LOC CODE OtST CODE AMOUNT RECEIVED CHECK N/CASH RECEIVED BY DATE RECEIVED <br /> Sfffflau mm�mmxm mm rv!a ..^r!,m^m? <br /> wm!ttu!vr:u:;;:um ;!xmr!ns:auaWmm!c?! <br /> ew 23 032 (REVISED 1.12.98) <br />