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SAK JOAQUINIC HEALTH SERVICES - EKVIROMMEIIT N TH DIVSION <br /> 4=RJBL <br /> STORAGE TANK PROGRAM - FEE <br /> SFACILITY SITE NAME FAIT ITY CONTACT NAME <br /> I c /(_z— / L/ i <br /> E FACILITY ADDRESS ITE PHONE # with AREA CODE <br /> & S7 TE ZIP CODE # of TANKS <br /> ClT� at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CTAC7 NAME <br /> L <br /> C MAILING ADDRESS PLICANT gH�ONE # WITH AREA CODE <br /> Al Eco C 7 <br /> N STkTE ZIP CODE APPLICATION <br /> T <br /> CITY Y' (Closur . Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1489 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 XXXX XXXX )d(XX $ <br /> A <br /> C XJ00( X)O(X xxxx 5 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E 1986 1987 1488 1489 1990 1941 1492 1993 1994 1945 1946 <br /> # Tanks = <br /> F (multiply appli!y—fee for S <br /> A each year cable) XXXX X)00( XXXX <br /> C S <br /> 1 TANK PENALTY FEES ASSESSED XXXX )000( XXXX <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T1991 through 1996 <br /> Y # Tanks x $56.00 1986 through 1940 <br /> (Enter amount and year) $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> TANK I.D. #(s) <br /> L # TANK(s) ? X 5234.00 = _ <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minis /TANK) c <br /> STANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R S <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 3234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A = $62400 minimum $ <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) . <br /> R REPAIR FEE (Workplan Review & Construction Inspeections) TANK I.D. #(S) <br /> — <br /> E <br /> P TANK LINING REPAIR FEE = 378.00/hour (3 hours minima/TANK) # TANK(s) X $234.00 = $ <br /> A $ <br /> I TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) = 5234,00 minimus <br /> R - ;234,00 mininum 5 <br /> PIPING REPAIR FEE = S78.00/hour (3 hours ■inimun/FACILITY) - <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr 5 <br /> I <br /> SS <br /> C CONSULTATION FEE = S78.00/hr SAMPLIXG INSPECTION FEE = S78.00/hr <br /> TOTAL DUE $ <br /> "'; —suAS#'� irtiriiilkFF <br /> L(X Cs50E fiZr "f�uHRtVil) � C1t—#7�ASiiti'I1i6mr <br /> Ear :g <br /> F< g iu <br /> EH 23 032 (REVISED 4-29-94) Page 11 <br />