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SAN JOACUINTY PUBLIC HEALTH SERVICES - ENVIRONMENT TH DIVSION <br /> ERGRODUD STORAGE TAM PROGRAM - FEE Lx <br /> :w <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> IN m ° ✓'YW <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 8 - - <br /> CITY C_ 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 # WITH AREA CODE <br /> A <br /> N 1 � <br /> - <br /> T CITY 1(!��E� <br /> ZIP CODE TYPE of APPLICATION <br /> �f (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 3100.00 <br /> A xxxx xxxx : <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx 3 <br /> I <br /> V TANK FEE = 350.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx xxxx 3 <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx f <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = f <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 378.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) = S234.00 minimum 3 <br /> R <br /> PIPING REPAIR FEE = 378.00/hour (3 hours minimua/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr f <br /> 1 <br /> S <br /> C CONSULTATION F = 378.00/hr SAMPLING INSPECTION FEE = 378.00/hr S <br /> �5 Ip TOTAL DUE S/� j <br /> FOR OFFICE USE ONLY 6� <br /> _.........._.-...._.........._................................ _.................... -..__. _ - .., ....-•.............. ......:::_-;::::-:::::: :,::::..«. ....._......................._........_...................,............«............. <br /> ::::::::::......... .... :::::::::............... ss.....::!s:::;:.........- ......................:; <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> _ .. ................................................................................... <br /> ::::::::::::::::::::::::::: _...««......... .........,.........I...................I. <br /> .........«..... ......I.. <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />