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SUI JOAQUIN CO" -Y PUBLIC HEALTH SERVICES - MR04MENTAL HEA TH DIVSIOM Uk,_2CUD STORAGE TANK PROGRAM - FEE WORKSHEET � 5 FACILITY SITE NAME / I FACILITY CONTACT JAME ANNUAL FACILITY FEE (Prior t0 January 1, 1991) = 5100.00 I J` S Xxxxxxxx A T -E FACILITY ADDRESS C T SITE PHONE % wich AREA CODE S XXXXXXXX 11W= XAMIKI Hour Dnlvv--2o — - a CITY STATE ZIP CODE At of TANKS at SITE A S Ck each year applicab(e) xxxx I xxxx I xxxx Cl l/I T S P P APPL IGNAME L I APPLI T NTACT Ng(IE CONTACT L T1Y % Tanks_ x 58.00 1988 thrcugn 1993 (S56) 1993 through 1997 (S56) 1998 (f) LL I C NAILING ADR 5 r SURCHARGE FOR 1998 I )=XXXXXXX)OOOIXXXXXXXXXXXXX DE APPLI TPHONE WITH AREA OCO-76 'S A L OI CLOSURE FEE = S78.00/hour (3 :hours minimum/TANK) I % TANK(S)_ X 523 .00' S UU �O ` N T C T STATE ZIP CODE TYPE f APPL[GTION S ,r /' A REPAIR FEE (Workplan Review 3 Construction Inspectials) I TANK I.O. #(s)— lasure Insca([acion, eco-) FOR OFFICE USE ONLY SVEEPS 3I COMPUTER % I LOC CODE DIST CODE AMOUNT RECEIVED I CHECK %/GSH I RECEIVED BY I DATE RECEIVED EH 23 032 (REVISED 1-12-98) 1986 11987 11988 1989 11990 ANNUAL FACILITY FEE (Prior t0 January 1, 1991) = 5100.00 xxxx XXX)( I xxxx wow I XXXx S Xxxxxxxx A C T FACILITY PENALTY FEES ASSESSED (If Applicable) I )=X I XXXx x= xnx xxxx S XXXXXXXX I V TANK FEE = S50.00/TANK (Prior Co�lanuary 1,1991) I 5170/TANK (After January 1, 1991, E' % Tanks = 1988 11989 11990 11991 11992 11993 11994 11995 11996 1997 11998 F (multiply % by fee for I XXXX (XXXX I I I I I S A each year applicab(e) xxxx I xxxx I xxxx Cl I I I I I S I TANK PENALTY FEES ASSESSED I )XXX I XXXX I xxxx I XXXX IxxxX I I L I STATE SURCHARGE FOR NEW FACILITIES ONLT=518.50 S T1Y % Tanks_ x 58.00 1988 thrcugn 1993 (S56) 1993 through 1997 (S56) 1998 xxxxxxxxxxXxxx=XXXXXX I S SURCHARGE FOR 1998 I )=XXXXXXX)OOOIXXXXXXXXXXXXX Cl PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.O. !(S)— L OI CLOSURE FEE = S78.00/hour (3 :hours minimum/TANK) I % TANK(S)_ X 523 .00' S 5 U TEMPORARY CLOSURE (Plan Review 3 [nspeciicre) R S2 E TEMPORARY CLOSURE FEE = 578.00/haw (3 hours mini mlm/FACILITY) I 5234.00 minimus -34 PI INSTALLATION PLAN CHECK (Plan Review b Construction Inspections)I TANK I.D. %(s) L A N PLAN CHECK FEE = 570/hour (8 hours minimm/FACILITY) = 5624.00 minimum 8.0 S R REPAIR FEE (Workplan Review 3 Construction Inspectials) I TANK I.O. #(s)— E P TANK LINING REPAIR FEE = S78.00/hour (3 haus minimum/TANK) % TANK(s) X 5234.00 = 5 A I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = SZ34.00 minimum S R PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = 5234.00 minimum S Ni TRANSFER FEE = S20.00 I I UNAUTHORIZED REL". J&WjjW O r I I 5 S C CONSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION FEE = S78.00/hr I I S FOR OFFICE USE ONLY SVEEPS 3I COMPUTER % I LOC CODE DIST CODE AMOUNT RECEIVED I CHECK %/GSH I RECEIVED BY I DATE RECEIVED EH 23 032 (REVISED 1-12-98)