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AMIL <br /> SAN JCWWIN STY PUBLIC HEALTH SERVICES . EWIROMMATAL On DIVBION <br /> UNDERGROUND STORAGE YAW PROGIM FEE UORKSHEST <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I ° t <br /> s <br /> T <br /> E FACILITY ADDRESS SITE PHONE # With AREA CODE <br /> VIC; c Q..o ot - <br /> CIT STATE ZIP CODE # of TANKS <br /> A C At SITE <br /> P SL <br /> P APPLICANT/BILLING NAME AP LtCAMY CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> A ® ° <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION SCA Ve," <br /> (Closure, installation, etc.) <br /> IOTA! <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX XXXX 5 XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX XXXX XXXX XXXX XXXX 5 XXXXXXXX <br /> I <br /> Y TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> N Tanks 1988 1989 1990 1941 1992 1993 1994 1995 1996 1997 1998 <br /> F (multiply 9 by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY418.50 $ <br /> T <br /> T Tanks x $8.00 1988 through 1993 ($56) 1943 through I"? ,(556) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXX)IXXXXX X $ <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Plaee) TANK I.O. #(s) <br /> 0 CLOSURE FEE = S78.00/hour (3 hours mini TANK) # TANK(S)- X w4.00 ' s ?Q d <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE . $78.00/hour (3 hours minimum/FACILITY) $234.00 mf nimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) LANK t.0. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE $ $78.00/hoar (8 hours mini FACtU TY) 5624.00 tm$n$ S <br /> R REPAIR FEE (Workplan Review ZR Construction Inspections) TANK I.O. 00) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hoar (3 hours minimum/TANK) A TANK($) X im.00 $ <br /> A <br /> I TANK RETROFIT REPAIR FEE 2 378.00/hour (3 hours min./FACILttY) ffi $234.00 mini5 <br /> R 5 <br /> PIPING REPAIR FEE = $78.00/hour (3 hours mini FACILITY) s $234.00 mini" <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION m 678.00/hr 5 <br /> I <br /> S <br /> C CONSULTATION FEE a $78.00/hr SAMPLING INSPECTION FEE * S78.00/hr s <br /> TOTAL DUE 2o— <br /> FOR <br /> OFFICE USE ONLY ax 11 magm! <br /> 3;1113MISC. 4 31 66w666i _ <br /> a SWEEPS S COMPUTER 0 LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> n:iIV i [f}E3S2H?aH°. r. ..a..?£H. . .. . s:i .i"ci4 :'S ,r s'RE$... ii I <br /> 3b83?!A&ia'!!3}66!6!!BE?i.BBi.:u.i.i668i 681E86_�5: 48 s.4. ... 3!8464 <br /> a" 71 nil (QFVtSF.O 1-12-98) <br />