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SFRV <br /> SA) JOAOUIM COUNTY PUBLIC HEALTH <br /> ENVIRONMENTAL iM DIYSIC0 <br /> UMDERG STETANKPROGRAMMKS14EET <br /> / FACILITY CONTACT NAME <br /> SI <br /> FACILITY SITE NA7>,E OS �S / n- / <br /> T I SITE PHONE At with AREA CODE <br /> E FACILITY ADDRESS (�j!, <br /> A y/p) STATE ZIP Caa i fSITANKS <br /> A CITY a <br /> �'�1 D <br /> p APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I I APPLICANT PHONE B WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 11989 11990 <br /> 1, 1991) = $100.00 0 <br /> ANNUAL FACILITY FEE (Prior to January XXXX XXXX �O ' 0 5 <br /> A / / S oO � <br /> C I XXXX X)=T FACILITY PENALTY FEES ASSESSED (If Applicable) 1991) <br /> I 5170/TANK (After January 1, <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) <br /> E Y tanks 1986 11987 1988 1989 11990 1991 11992 11993 1994 1995 1996 <br /> = _ IF (multiply T _ XXXX by fee for I � I O (/ri <br /> A each year appticable) XXXX �j I S <br /> C I I 5 <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Cote, section 2528 <br /> T1988 through 1':: 1991 through 7996 <br /> T Y Tanks- X 556.00 0 0 S <br /> (Enter amount and year) O <br /> 4 <br /> TANK 1.0; (s)' <br /> CD£RMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> L d T'NK(s)� X $234.00 L <br /> 0� CLOSURE FEE - 578.00/hour (3 hours minimum/TANK) ✓. <br /> Sl TANK I.�Xn - <br /> U TEMPORARY CLOSURE (Plan Review & ImPections) <br /> R S <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours miniaam/FACILITY) 5234.00 minims <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK 1_0. i(s) <br /> L <br /> A = 5624.00 minimum S <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) <br /> R REPAIR FEE (Workplan Review & construction lrspeciiore) <br /> TANK I.D. 9(s) <br /> E S <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) x TANK(s) __ X 5234.00 = <br /> A S <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min-/FACILITY) = 5274.00 minimus <br /> R = 5234.00 minimum S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mi nimum/FACILITY) <br /> N TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> 5 <br /> 1 <br /> S = 578.00/hr I S <br /> C CONSULTATION FES = 578.00/hr SAMPLING INSPECTION PEE <br /> TOTA1. DUE _ ! J <br /> FOR OFFICE USE ONLY <br /> =�T even CHECK <br /> _/CASH .RECEIVED ni rE RECEIVED <br /> S1lE'=PS S CCMPUTER LOC CODE 01sT CODE ;�rnaihT ^_'•E••"' /CASH <br /> 5__ <br /> EH 23 032 (REVISED 10-28-93) page <br />