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SPA JORGIIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL. HEALTH OIVSION <br /> UMF" 1UND STORAGE TANK PROGRAM - FEE W1ISHM <br /> tLtn DISE a _�- FAet (n xxrAa abs <br /> E <br /> FACILITY 1A00R' E� ( SITE iXOMt N ufNAMA 009 <br /> -*j3Z,16B <br /> A ctn / _ I E VZSY ®t t of Tf <br /> C/�FTFs�•/^� � ae SITEE <br /> v <br /> ` avvLl rp(ylxG x SIN 2FN� APvu(:ANT aJ <br /> AD-Z V.N <br /> C <br /> MAKING AOORE35 APPLICANT PRONE N YITN MEA CCOE <br /> 6 r�(o� 2c�}p Sao 15363 <br /> T CITY T STATE 2IP CWE TTP PLICATION <br /> �p'D ��4 aura, ra:a LILT <br /> TOTAL <br /> 1986 1987 1988 11989 I 1990 <br /> ANNUAL FACILITY FEE (Prior :a Jaaury I, 1991) + 3700.00 <br /> i A XlOI% %XXX %%%% p(%% %X%% S Xf00IX%%% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) KDOt xxxx I )ODD) I xccx I x000; 5 lococc ac <br /> V TANK FEE • S50.00/TANK (Prior to Jacuary 1,1991) I 5170/TANK Ufnr January 1, 19911 <br /> E i Tanks + 1988 11989 11990 11997 11992 11993 11994 1995 I 7996 1997 1998 <br /> F (mutcipl7 _bT fas far <br /> A each Year applicable) 1410) 11000f ]OOOI I woG I1000f I S <br /> 1 TANK PENALTY FEES ASSESSED I %R:CI I XKIX IDI%% 110xx I=cx I I I I I I S <br /> L <br /> I STATE SURCNARG"c FOR NEW FACILITIES ONLY+178.50 5 <br /> T <br /> T ! Tanks_A 58.00 1988 Nraugh 1997 ($56) 1993 Nrw9h 1997 (356) 1998 <br /> SURCNARGE FOR 1998 5 <br /> C PERMANENT CLOAIRE (Rmw•l ar Authorized CtmurO-in-Plop* TANK I.Q. N(s) <br /> L oNp <br /> 0 ttOSURE FEE • '78.00/hwr (7 hwn minimmVTAN[) I i tAXK(s)_ % 5234.00 • t Z•9g ,� <br /> S <br /> U TEMPORARY CLOSU0.E (Plan Rwiw d Irapecciam) RANK 1.0. s(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • 578.00/bar (3 hwn minlmWFACi LITY) I 3274.00 ainimAe 5 <br /> PI INSTALLATION PUN CHECK (Ptah Rwiw i cmmstn tfm fmpeeti anal TANK I.O. N(s) <br /> L <br /> A <br /> N PLAN CHECX FEE a 573.00/hour (q hwn minimNFAC[LITY) • 3624.00 minimm S <br /> RI REPAIR FEE (Workplan Rwiax i Cmmtlu Him Impatitaro) TANK L0. Y(s) <br /> E <br /> P iANX LINING REPAIR SEE • 578.00/hour (3 bars minfma/TANK) N TANK(s) — K $234.00 • S <br /> A <br /> [ TANK RETROf 1T 0.EPAIR FEE • SMOG~ (S hors min./FACILITY) • M4.00 minimae S <br /> R <br /> PIPING REPAIR SEE • 578.00/Har (3 hwn minleWFAC[L[TY) a 5234,00 minieun S <br /> NI 1RAx5FER SEE • 520.00 I UNAUTMORIM RELEASE EVALUATION • 578.00/hr I I S <br /> t <br /> C CONSULTATION SEE • 578.00/M1r SAMPLING INSPECTION FEE • 578.00/hr I I S <br /> TOTAL DUE 5 <br /> FOR OFFICE USE O LT <br /> SWEEPS Y COMPUTER At LOC CSE GIST CWE AMOUNT RECIVEO CHECK :/USH RECEIV© BT GATE .RELIVED <br /> EH 23 032 (REVISE] 112-98) <br />