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SAN JCADUIN COUN,% PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAv DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I S wue✓ , <br /> "E fACIL1TY ADD ESS SITE PHONE # with AREA CODE <br /> t �roaclWa <br /> CITY STATE ZIP CODE of TANKS <br /> A 5t wor C4 at SITE <br /> gSaD� <br /> P APPLICANT CONTACT NAME <br /> P APPLICNT/BILLLINGNAME <br /> L SQyL <br /> ab <br /> I <br /> APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N i STATEi ZIP CODE TYPE of APPLICATION <br /> TI CITY (Closure, Installation, etc.) <br /> ra <br /> TOTAL <br /> 1986 11987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A %XXX I %XXX XX%X %XXX XXXX S %XXXX%XX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XX%X %XXX xxxx XXXX XXX% f %%XXXX%% <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,7991) 5170/TANK (After January 1, 7991) <br /> E <br /> 9 Tanks = 1988 1989 11990 1 7991 11992 11993 I 1994 1995 11996 11997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) %XXX XXXX xxxx XXXX XXXX I I I S <br /> C <br /> I TANK PENALTY FEES ASSESSED I xxxx XXXX xxxx I XXXX Ix%xX I I I I I I S <br /> L- <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=S1a.50 $ <br /> T <br /> T # Tanks_ x 38.00 1988 through 1993 (856) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 %XXXXXXxxxxxxxxxxXXXXXXXxxx XXXXXXXXXXXX)D(XXXXXXxxx S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK 1.0. #(s) <br /> L <br /> 0 CLOSURE FEE = 278.00/hour (3 hours minimun/TANK) # TANK(s) X 5234.00 = 13 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum 1 S <br /> P INSTALLATION PLAN CHECK (Plan Review S Construction Inspections)I TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review E Construction Inspections) I TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = { S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) _ $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE = SZ0.00 I UNAUTHORIZED RELEASE EVALUATION - 578.00/hr I S <br /> I <br /> S �ClCONSULTATION FEE = 578,00/hr I I SAMPLING INSPECTION FEE = f78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> —iilimlummi .:a_=.^:: �' :�_,— =:::._:.- �:�:+�._....., ,M�_ <br /> SWEEPS # 1 COMPUTER % LOC CODE �DIST CODE AMOUNT RECEIVED CHECK A!/CASH RECEIVED dY DATE RECcIVED - <br /> ::::::.�.. <br /> =w 74 nl;) (RFVISFO 1-12-98) <br />