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SAN JOAQUINCOULIC HEALTH SERVICES - ENVIRONMENTAL IVSION <br /> UNDEa STORAGE TANK PROGRA14 - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T I Lott cS <br /> 'E FACILITY ADDRESS SITE PHONE 0 with AREA CODE <br /> & tV S�� Ic G <br /> CITY n TATE ZIP CODE 0 of TANKS <br /> A <br /> tvV at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I 1 IC 9LA IbI <br /> C MAILING ADDRESS APPLICANT PHONE 9 WITH AREA CODE <br /> n <br /> N <br /> T) CITYSTATE ZIP CODE I TYPE of APPLICATION <br /> (Closure, Installation, etc. <br /> TOTAL <br /> 1986 1487 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E <br /> N Tanks = 1988 1989 1990 1 1991 11992 1993 1994 1995 11996 ( 1997 1998 <br /> F (multiply * by fee for <br /> A each year applicable) XXXX XXXX I XXXX XXXX XXXX I S <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX XXXX XXXX IXXXX I I f I 5 <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY='518.50 5 <br /> T <br /> Y # Tanks x $8.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSUR (Removal Authorized Closure-in-Place) V I TANK I.O. x(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I tt TANK(s) X .5234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. x(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. *(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimtxn/FACILITY) = S624.00 minimum TS <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. 0(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I S <br /> I I 1 <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr I S <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY <br /> M c».M!iR!ii4??.a::'»!i»:s'!f»xis::'•-Tsn••x•r;.n.,�.i»L.'"�Se!!!!iii!:i!nes r._?g»i'»r_r,.rxa=:::r.:e.._..._.....:.••- ..c:....:m»'.-:s:c_..---:�c „—rte;-.z x:s..�s_.°.p:_._ _ _ '»eee�sn'?�.�.-' i»i^':.° <br /> iuii::i°.^_i".•�.iiiw�'iGiw:�::::i»:srsu:ssssssax c:.�iui&i'ui»imdi!a'ii»°.i»3e:'_:mu:�a�ua�i.:iiix�:Ssli'•ax"'ii'�ii»Eeen�::_�"•'-':n' ••_. �-r•'.:�• arssr Y::"ss"•••._• on••-_• ..:samz:: <br /> SWEEPS X COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK */CASH RECEIVED 3Y DATE RECEIVED i <br /> i <br /> 5 i <br /> :.:rn s::a::xiEi':g.»»3i.:.eE�'?iii::�a?if3iii:'�..'»F.:.::�!ii.:!e'!n»iFi!»?'45:.'s!»ann::"•»»r::.::..�.. aa::�ss::as:::.r..::an::a:.x:•�-m��i:T:..r ms,:r.�i...�Eii'�::...i?::::Tii!:'�:ir.:::—.:x:a�»�:^»aasr..r.....�..�=...e.......^i;}'i»:ex E <br /> i-...rte»._._.. __. _.......::.:..._»....._... .........__ .._.._.... .�__ .. ... <br /> ian..'I»i»iMM 2:._:.,..u:iri»:;�::::iiia'.5.nr•^.'-•::•3s.''�ii'w'»::_ar.^r.�r•»:. r., ......._:.r�:»iia}zs :":. :a.:a•":ia:iiF. =;-n'= ......._...—•.s_. _::.—.___::::.3•ri:i: !ii5i3ccz::_.. —."�.._�::.rte:-'Tai4' »ii! <br /> ow 7C n47 rRFvtsFD 1-12-981 <br />