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SAN "QUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH 0 MION <br /> UNDFOGROUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SI =AGILITY SITE NAME FACILITY CONTA- NAME <br /> I� <br /> TI <br /> E FACILITY ADDRESS I SITE PHONE t with AREA CODE <br /> CITY I STATEI ZIP CODE 4 of TANKS <br /> A at SITE <br /> P <br /> PI APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C1 MAILING ADDRESS APPLICANT PHONE WITH AREA CODE <br /> A <br /> T! CITY STATEI ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> j 11986 ` 1987 1988 11989 11990 <br /> AI ANNUAL FACILITY FEE (Prior to January 1, 1991) = 3100.00 <br /> XXXX I XXXX I XXXX I XXXX XXXX 5 XXXXXXXX <br /> C� <br /> TI FACILITY PENALTY FEES ASSESSED (If Applicable) I xXXX XXXX I XXXX I XXXX XXXX 3 XXXXXXXX <br /> I <br /> V; TANK FEE = 350.00/TANK (Prior to January 1,1991) I 3170/TANK (After January 1, 1991) <br /> E; 4 <br /> j Tanks = _� 1 1 <br /> 1988 i 1989 i 1990 1991 1992 ' 1993 i 1994 11995 1996 i 1997 1998 <br /> F1 (multiply 4 by fee for <br /> A� each year applicable) ! XXXX xXXX I XXXX XXXX XXXX I i 5 1744, <br /> C' <br /> 11, TANK PENALTY FEES ASSESSED XXXX XXXX i XXXX XXXX ;XXXX <br /> L. <br /> Ij STATE SURCHARGE FOR NEW FACILITIES ONLY=51-70' <br /> T' <br /> YI T Tanks 2 x 38.00 ( 1988 through 1993 (556) 1993 through 1997 (556) 1998 6 <br /> j <br /> SURCHARGE FOR 1998 ` XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX 3 <br /> C1 ?ERMANENT CLOSURE (Removal or Authorized C,osure-in-P(ace) TANK L.J. .+'(s) <br /> L. <br /> 01 CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) + TANK(s) X 5234.00 = 5 <br /> S, iii <br /> UI TEMPORARY CLOSURE (Plan Review b Inspections) TANK L.J. +Cs) <br /> R' <br /> E; TEMPORARY CLOSURE FEE = 378.00/hour (3 hours minimum/FACILITY) i 3234.00 minimum 3 <br /> PI INSTALLATION PLAN CHECK (Plan Review I Construction Lnspec:ions)I TANK I.O. T(s) <br /> L; <br /> Al 7�NI PLAN CHECK FEE = 378.00/hour (8 hours minimum/FACILITY) = 3624.00 minimum 5 (O L <br /> RI REPAIR FEE (Workplan :Review 3 Construction Inspections) TANK I.O. +(s) <br /> E' <br /> P1 TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I TANK(s) X 5234.00 = 3 <br /> A <br /> 1; TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) = 3134.00 minimum 3 <br /> R <br /> PIPING REPAIR FEE = 378.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum 3 <br /> MI TRANSFER FEE = 320.00 I i UNAUTHORIZED RELEASE EVALUATION = 378.00/hr I I S <br /> S. <br /> CI CONSULTATION FEE = 378.00/hr I SAMPLING INSPECTION FEE = 578.00/hr I 5 <br /> TOTAL DUE 3 <br /> FOR OFFICE USE ONLY <br /> _ ...__.— ..._._...... <br /> SWEEPS COMPUTER T i LOC CODE I GIST CODEI AMOUNT RECEIVED I CHECK »/CASH I RECEIVED 3Y DATE RECEIVED . <br /> EH 23 032 (REVISED 1-12-98) <br />