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'9%N JOAQUIN COUNTY PUBLIC HEALTH SER <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM .FEE WORKSHEET <br /> 5 FACILITY SITE NAME FACILITY CONTACT NAME? <br /> T ReC KK r-51 l�+ <br /> E FA I TTY ADORE ITE XONE # with RFA CODE <br /> & 5 b Gt od, S2L1 h 6 <br /> LAr tl .I ev yf�TE ZIP CODE # of TANKS <br /> CL 11{ �y"ZZj(n at St TE Z <br /> APPLICANT/BILLING�INuT/BCI LLLING NAXE APp_P�L IC�.tIT NTACTI <br /> (y( ffd bu <br /> N� ADDr,RESS L_ I LICAN PRONE # wITX AREA CODE <br /> 7µ t Zr�4) SZy- h�3 <br /> CATION <br /> �CteFSI (C31P CODE tasure Pfnsaltaticn, etc.) J Ne Lo VOL <br /> �� TOTAL <br /> ATANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> C <br /> T # Tanks 19864 1987 1988 1989 1 1990 1991 -1 1992 1 1993 1994 1995 1996 <br /> I (multiplyF6Y—fee for <br /> .. E each year applicable) XXxx XXXX xXXX XxxX XXXX s <br /> TANK PENALTY FEES ASSESSED I xxxx XXXX XXXX XXXX XXXx S <br /> S <br /> T STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> E # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. Y(9) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimae/TANK) # TANK(s) 2- X 5234.00 5 (q <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/FACILITY) 5234,00 minimae 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) X 5234.00 S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimae S i <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum 3 <br /> N TRANSFER FEE = S20.00 <br /> 11 <br /> RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE - 578.00/hr 'SI // <br /> TOTAL DUE "I b0 fJb <br /> ,_FOR_.Q.f.E.I.CE_.USE_011,17 <br /> _ _...__. :. <br /> supEPS �onpGTE k Lot cDDE- tsf-CODE a'riaNT 2EGE"fG'ED C EcKGTsI RE'CEITiED 9 6ai AEG CV'E5 <br /> �p <br /> fi � I I � !a <br /> y n <br /> 111m'awea:e:vn.-z.'.�n <br /> ._._uu_.__...__...__...... <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />