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SMI JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ELVIROWFYTAL HEALTH DIVSION <br /> UN IAD STORAGE TANK PROGRAM - FEE WCWHEET <br /> S FACILITY SITE NAME FACILITY CONTA f NAME <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & 7S7 F <br /> CITY STATE ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE 9 WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) )OCOC )COON S <br /> I <br /> V TANK FEE = 250.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E # �V <br /> Tanks 7986 1987 1988 1989 1990 1991 1492 7993 7994 1995 1996 k <br /> F (multiply # by fee for <br /> A each year applicable) �1 <br /> C <br /> I TANK PENALTY FEES ASSESSED )D= xxxx S <br /> L <br /> I STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T L— <br /> Y # Tanks x S56.00 1986 through 7990 1991 through 1996 <br /> (Enter t and year) 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Cl osure-in•Place) TANK I.D. #(s) <br /> L # TANK(s)_ X 5234.00 - 5 <br /> 0 CLOSURE FEE - 578.00/hour (3 hours minio-WTANK) <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & ImPections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimu=/TANK) # TANK(s)_ % SZ34.00 ' $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L J <br /> N PLAN CHECK FEE 578.00/hour (8 hours minimm/FACILITY) ' 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> P TANK LINING REPAIR FEE - 578.00/hour (3 hours minimum/ IS <br /> TANK) # TANK(s) _ X 2234.00 = <br /> AS <br /> I TANK RETROFIT REPAIR FEE - S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br /> R5 <br /> PIPING REPAIR FEE ' 578.00/hour (3 hours mi ni uAW FACILITY) = 5234.00 minium <br /> M TRANSFER FEE 520.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr S <br /> I <br /> S . 578.00/hr S <br /> C CONSULTATION FEE ' S78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL [MJE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS # I COMPUTER # I LOC CODE DIST CODE AMWWT RECEIVED CHECK #/CASH RECEIVED BT DATE RECEIVED <br /> _ 3 <br /> S <br /> EH 23 032 (REVISED 11.1.92) Page 11 <br />