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SAM JOAQUIN COUNTY'PrMLIC HEALTH SERVICES - ENVIRONMENTAL NEALTH)POSION <br /> UNDERGRa= STORAGE TANK PROGRAM - FEE WORKSHEET <br /> Si FAC:L?TY SITE N E FACILITY CONTACT WANE <br /> I <br /> T SITE PHONE x with AREA CODE <br /> .E FACILITY ADDRESS <br /> t �j c <br /> cl,� ;7A,jE ZIP CODE I x of TANKS <br /> at SITE <br /> A y <br /> P APPLICANT CONTACT NOE <br /> PFpe <br /> T ILLI NG �E <br /> L `O•�C�• izcx� �- <br /> I APPLICANT PRONE R WITH AREA CODE <br /> CAOD SS S-U - - - <br /> TI�� I�STATE] 7jCODE TYPE of APPLICATION <br /> Jry�J�•- (Closure, Instal lacion, etc-7 <br /> TOTAL <br /> 1986 11987 11988 11989 19% <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> xxxx xxxx xxxx 1 xxxx I xxxx s xxxxxxxx <br /> A <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> xxxx I xxxx I xxxx xxxx xxxx s xxxxxxxx <br /> II 5170/TANK (After January 1, 1991) ' <br /> V1 TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E' <br /> Al Tanks = 1988 11989 11990 1991 11992 � 1993 1994 11995 11996 � 1997 1998 <br /> F (multiply N 5Y fac for I I I I g <br /> A� each year applicable) xxxx XXXX I xxxx xxxx XXXX <br /> C <br /> 11 TANK PENALTY FEES ASSESSED I XXXX XXXX I XXXX I xxxx (xxxx I I I S <br /> L 5 <br /> 11 STATE SURCHARGE FOR NEIL FACILITIES ONLY-S18-50 � <br /> T <br /> Y 4 Tanks_ x 58.00 1988 :hrough 1993 (556) 1993 through 1997 ($56) 1998 <br /> SURCHARGE FOR 1998 )DOXXXXXxx =XXXXXXXXXXXXX %%XXXX%X%XXx%XXXX%%XXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) ( TANK I.0, x(s) 1i <br /> L x x234 A0 I S ��• U <br /> 0 CLOSURE F=E = S73.00/hour (3 hours miminAWTANK) C TANK(5) <br /> S. <br /> Ul TEMPORARY CLOSURE (Plan Review 3 Inspections) I TANK I.D. 2(s) { <br /> R r— S <br /> El TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) I 5234.00 minimum <br /> pi INSTALLATION PLAN CHECK (Plan Revia d Construction Inspections)I TANK I.D. X(s) <br /> L <br /> A 5 <br /> MI PLAN CHECK FEE = 578.O0/hour (8 hours minimm/FACILITY) = 5624.00 nimmm <br /> R REPAIR FEE (Workplan Review 3 Construction Inspections) TANK I.D. S(s) <br /> E X 5234.00 = + s <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /> x TANK(s) <br /> A <br /> I I ; <br /> TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = $234.00 minnow s <br /> N TRANSFER FEE = 520.00 I I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I { 5 <br /> I I i <br /> S i 5 <br /> C. CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = S78.00/hr i <br /> TOTAL DUE l /X70 <br /> FOR OFFICE USE ONLY <br /> -y' <br /> SWEEPS x COMPUTER Y LOC LODE f 0[ST CODE AMdJNT RECE?VED CHECK %/CASH RECEIVED 3Y <br /> yz:L., GATE RECE?VED - <br /> s <br /> r <br /> iTZIIT.;l <br /> (QFVi SFD 1-12-98) <br />