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SAIL JOAQUIN C> PUBLIC HEALTH SERVICES - EXVIRCKMEXTAL H0IVISICN d N STA LL— <br /> UNDEAWND STORAGE TANK PROGRAM - FEE WORKSHEET or <br /> S FACILITY SiTE NAME FACILITY CONTACT NAME <br /> I &F L l L_P 61 LQpr Be LL U0HrJ F RRcS <br /> T <br /> E FACILITY ,ADDRESS SITE PHONE 0 with AREA CODE <br /> KE7TLEY►��kr� L� (Z09)3 651 5`630 <br /> CITY �© ►J 1 STATE ZIP CODES of TANKS (I)Q rL16DO &AL. <br /> P G �SZ l u at SITE 3— (1)SPLIT (r, 11/00o &AL <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L M f KE LEE <br /> Ii <br /> C. MAILING ADDRESS D x ��`� APPLICANT PHONE 4 WITH AA CCDE <br /> E <br /> A �1'J <br /> N <br /> T CITY STATE ZIP CODE TYPE of APnsta(Lation )NSTA L!_ <br /> L0o D� q rj z�- y (Closure,, etc.) <br /> TOTAL <br /> 1986 1487 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A XXXX XXXX XXXX XXXX XXXX s XXXXXXXXXXxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If App(icable) XXXX XXXX XXXX XXXX XXXX 5 xxxxxxxxxxXXX <br /> I <br /> V� TANK FEE = 350.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E 4 Tanks = 3 1986 11987 1988 1989 11490 1991 1992 11993 1994 1995 1997 �a <br /> F (multiply 4 by fee for <br /> A each year applicable) XXXX XXXX xxxx I XXXX I XXXX 171) s 510 <br /> C' <br /> [I TANK PENALTY FEES AS.SESSEO I xxxx xxxx ! xxxx XXXX XXXX S <br /> L <br /> II STATE SURCHARGE = S $.00/TANK O �gs7 <br /> Ti <br /> Y $18.510/FACILITY <br /> C PERMANENT CLOSURE (RemovaL or Authorized Closure-in-PLace) I TANK I.D. »(s) <br /> L <br /> O+ CLOSURE FEF = 378.00/hour (3 hours minimum/TANK) I TANK(s) X 5234.00 = 5 <br /> S' <br /> Uf TE..HPCRARY CLOSURE (PLan Review & Inspections) TANK I.D. 4(s) <br /> R, <br /> El TEMPCRARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 3 <br /> P� INSTALLATION PLAN CHECK (Ptah Review & Construction Inspections) TANK I.D. l(s) <br /> L <br /> A <br /> H PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5524.00 minimum S �� [ <br /> R REPAIR FEE (Workp(an Review & Construction Inspections) TANK I.O. Cs) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) A~ TANK(s) X 5234.00 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> MI TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S' <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> ...— .. — <br /> SWEEPS # I COMPUTER 4 I LOC CODE DIST CODE I AMOUNT RECEIVED ! CHECK 4/CASH I RECEIVED 3Y DATE RECEIVED <br /> " S <br /> .,. .:_::µ.ms:..„„,,;„.._...."..._......__„.�:_..... <br /> REVISED' O3c�V0'6' *7 -- ------. - <br /> 9 <br />