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SAN JOADUIM COUNTY--?lURLIC HEALTH SERVICES - ENVIRONMENTAL NEALT"VSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME # FACILITY CONTACT NAME <br /> I 7Cv Facili} 4401 <br /> T 0��43 <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> a I5b2 N, et Dorado St. <br /> CITY STATE ZIP CODE # of TANKS <br /> A cj}pckton GQ, 9cbZ04 at SITE 3 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I L oe V% brWF, Inc . jai a C�ianiv+a <br /> C MAILING ADDRESS APPLICANT PRONE # WITH AREA CODE <br /> " 1 D illowD Pass iZoad `7g 4Lb ;12s- C004I -G3ob <br /> N 7a„k <br /> T CITY I STATE ZIP CODE TYPE of APPLICATION <br /> GOnGOrGi GA �MSZ0 (CLosure, Installation, etc.) 610SUre� <br /> TOTAL <br /> 1986 1987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.D0 <br /> A XXXX xxxX I xXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xXXX XXXX xXXX XXXX xXXX $ XXXKXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 11996 1997 1998 <br /> F (multiply # I fee for <br /> A each year applicable) XXXX XXXX xXXX I XXXX XXXX I S <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX I xxXx xxxx I XXXX IXxxx I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=S18.50 S <br /> T <br /> Y # Tanks x $8.00 1988 through 1993 (S56) 1993 through 1997 ($56) 1998 <br /> SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxXXXXX xxxxxxxxxxXXXXxxxxxxxxx S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X 5234.00 = S 707— ,0C> <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 mini mm S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimm S <br /> RI REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minima/TANK) # TANK(S) _ X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 mini mm S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I � i <br /> S <br /> ClCONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 878.00/hr I S <br /> TOTAL DUE 5 70 2•°D <br /> FOR OFFICE USE ONLY _ <br /> ......._..........._. ..._........_. ................._..._. .... �:::... ..— _. <br /> SWEEPS <br /> COMPUTER <br /> CODE <br /> DI C s_u AMOUNT..__._s_...............CHECK <br /> At 'ire <br /> SWEEPS # COMPUTER # LOC LWE D[57 CODE AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> 5 <br /> ::!............_.......__....._....... :...::::::vim n::. i iicm...:::::.::::. .._�_..._..v.�.-._5__..i_-':'x.: "L:.P _ <br /> ..... ........_ :::v v..._...__.........._................_....._ _..._...._.._...........vc..:..:x:..:::ay.: <br /> eN Pi nt7 CRFVISFO 1-12-98) <br />