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SAN JIMOUIN C •Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL Hr -H DIVSIOI <br /> U%WXGR0UN0 STORAGE TANK PROGRAM - FEE WORKSHEEv <br /> S FACILITY S TE NAME FACILITY CONTACT NAME <br /> �(ps t L.lS7� �1f'e�l G- <br /> T <br /> "E FACILITY AOORE55 SITE PHONE # with AREA CODE <br /> L _ <br /> CITY STATE ZIP CODE # of TANKS <br /> A �v4� o Q �- 330 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT s CONTACT �T NtAME <br /> L Sp� �v- ID W e, <br /> I <br /> C MAILING ADDRESS APPLICANT PRONE pj <br /> #��WITH AREA}�CODE <br /> " -1 rAV IAIn Oct - .S bSt <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> Lluet�vo RS'33e� (Closure, Installation, etc.) ���� <br /> TOTAL <br /> 1986 1 1987 11988 1 1989 1 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A %XXX I %XXX I XXX% xxx% XXXX E XXXXX%%% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX xxxx I X%XX I XXX% I XXXX <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 2170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 11996 1997 1 1998 <br /> F (multiply Al by fee for <br /> A each year app(icable) xxxx XXXX I XXXX %xxx XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED %XXX XXXX I XXXX I %XXX %XXX S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY-$18.50 <br /> S <br /> T <br /> Y # Tanks_ x $8.00 1988 through 1993 (256) 1993 through 1997 (556) 7998 <br /> SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxx xxx%xxxxxxxxxxxxxxX%xxx 2 <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 minimun/TANK) # TANK(s)-4;-1- X 5234.00 = E <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 278.00/hour (3 hours minimm/FACILITY) 1234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) 5624.00 minimum E <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK l.D. #(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 /> 1 TANK RETROFIT REPAIR FEE = 278.00/hour (3 hours min./FACILITY) = 2234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mininuNFACILITY) = 5234.00 minimum 2 <br /> M TRANSFER FEE = 220.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> t <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 278.00/hr S <br /> TOTAL DUE S LA&,b <br /> FOR OFFICE USE ONLY �.n <br /> ......_._.... _ ... ...ew�..�:F ea=.ma"r:!a_�a°=:_-a+. �. :.ORE-::-:�:,�+:.._�,,__ro,:;� <br /> -:ac,:_�r:r:r,:!r::crr::c:xa�::c:--::�:.-.-.::.-�.,:a::::_�:;:,:::,:!_.�:�a'=r=:_�__.__y,,..�:....__r�,:: .:..:.rc!:::-:__:s:�-,.�.- <br /> B SWEEPS # I COMPUTER # LOC CODE �D IST CODE ANOl1NT RECEIVED CHECK #/LASH RECEIVED BY DATE RECEIVED <br /> 5 <br /> -_:. ::...._.:mma!:!r: :: ::r-.-.:! <br /> EH 23 032 (REVISED 1-12-98) <br />