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SAN 1oAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> L=FRqd@h0 STORAGE TANK PgOGRAM - FEE WORKSHEET <br /> 5 FACILITY SITE NAME FACILITY C;NTACT E <br /> 3t5gEYY� <br /> T SITE PHCNE 4 With .AREA MOE <br /> -'E FACIC[TY ADDRESS <br /> rn EA ILLLO-bA4 <br /> ` $TAE ZIP CCOE '. of TANKS <br /> CITY _ .l at SITE <br /> A <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING ?TAME E � nc <br /> L 1 <br /> I AP ICANT PHCNE WITH AREA CCOE <br /> C MAILING ADDRESS <br /> N }1[ STATE ZIP CODE 4 IY e of APPLICATION <br /> T CITY ! C�1 k (CLasure, [nstallation, etc.) <br /> 1 <br /> TOTAL <br /> 1986 i 1987 1988 F 1989 11990 <br /> ANNUAL FACILITY FEE (Prior to lanuary 1, 1991) = 5100.00 XXxX XXXX XXXX XXXX XXXX 5 XXXXXXXX <br /> A 9 <br /> CE XXxX i xxxx I Xxxx ` xxxx I xxxx 5 Xxxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If AppLicabLe) I <br /> I3170/TANK (After Jaruary 1, 1991) <br /> V TANK FEE = s5U.00/TANK CPrior to January 1,1991) <br /> E' <br /> Tanks = 1988 1989 11990 1991 1992 11993 , 1994 } 1995 i 1946 1997 1998 <br /> F (multiply $ by fee far s <br /> A each year applicable) xxxx XXXX XXXX xxxx ixxxx <br /> Cl <br /> r <br /> I TANK PENALTY FEES ASSESSED ` xxxx xxxx xxxx 4 xxxx �Ixxxx <br /> L 3 <br /> II STATE SURCHARGE FOR NEW FACILITIES ONLY-318. 3 <br /> T1988 through 1993 (s56) I 1993 through 1997 (556) 1998 <br /> Y M Tanks x 38.00 <br /> I XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX <br /> SURCHARGE FOR 3998 3 <br /> C� ?ERMAHENT CLOSURE (Removal or Authorized CLasure-in-Place) TANK I.G. »(s) <br /> L 1 TANK(s) +� X 5234.00 <br /> OI CLOSURE FEE = 578.30/hour (3 ;hours ninim.ma/TANK) <br /> S I TANK [.0. #(s) <br /> UI TEMPORARY CLOSURE (PLan .Review 3 Inspectiorss) <br /> R <br /> .00/hour (3 hours minim�sn/FACILITY) I 3234.00 minim= <br /> E TEMPORARY CLOSURE FEE = 378 <br /> P{ [NSTALL.ATION PLAN CHECK (Plan Review & Ccnstruction [nspeCtions)� TANK I.D. (s) <br /> L <br /> A r = 5624,00 minimur Ts <br /> N PLAN CHECK FEE = 578.00/hour (8 hours mirsimcn/FACIL.TY) <br /> RI .REPAIR FEE (WorkpLan Review ; Construction InspeCtions) TANK E.O. 4(s) <br /> E X 3234.00 = S <br /> P TANK _[NTNG REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I TANK(s) <br /> A = 5234.00 mini-En TANK RETROFIT REPAIR FE= = S78.30/hour (3 hours min./FACILITY) <br /> R = 5234.04 S <br /> ?[PING REPAIR FE'_ = 578.03/hour C3 hours minimums/FACILITY? minim.m <br /> MY TRANSFER FEE <br /> 520.00 , UNAUTHORIZED RELEASEE EVALUATION = 578.00/hr I } 5 <br /> ti i I <br /> S <br /> C CONSULTATION FEE = 378.00/hr � SAMPLING INSPECTION FEE = 378.00/hr � <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPSI- COMPUTER I LOC CODE I QIST CCA€ AMOUNT RECEIVED CHECK �/CASH ' RECEIVED 3Y GATE RECEIVED <br /> "cH 23 032 (REVISED 1-12-98) <br />