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SNI JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SFAC(LI SITE NAME ^ FACILITY CONTACT NAME <br /> T Z VI. J <br /> E FACT ITY ADORE S ^ SITE PHONE # with AREA CODE <br /> & J71 <br /> A CITY STATE ZIP CODE # of TANKS <br /> P G at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A �{ <br /> N l <br /> T CITY E ZIR CODE PLICATION <br /> 9a5-35 (Closure Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A & <br /> C <br /> TFACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX g <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> 4! Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicab(e) <br /> C- <br /> I <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 Code, Section 25287 <br /> 7 <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> mo <br /> (Enter aunt and year) <br /> q <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. #(s).3 <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s)� X $234.00 <br /> S 04 <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s)_ X 5234.00 S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimm/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 _ &78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED REL-EASE EVALUATION = $78.00/hr S <br /> Sl I <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = 578.00/hr $ <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY <br /> unox <br /> C LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVEDW �3 <br /> s = <br /> EN 23 032 (REVISED 11-1-92) • Page 11 <br />