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S JOAQUIN COUNTY PUBLIC HEALTH RV,.E=-.i <br /> ENVIRON�NTAL HEALTH DI WCGHEET <br /> ER i STORAGE TANK PROGRAM - <br /> S FACILITY SITE NAMEFACILITY CONTACT NAME Slo� $`IZ- y�83 <br /> I Foa+hFR C1�€ 12u J fLCi -(plS�; LAXILI w ct1AC <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESSukr:9 C Aid <br /> E �qiN N <br /> & STATE ZIP CODE I # of TANKS <br /> CITY at SITE <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> NIP CODE I TYPE of APPLIGiTION <br /> T CITY (Closure, insta Nation, etc.) <br /> TOTAL <br /> A TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> T # Tanks = 1986 1987 1988 1989 1990 1991 1992 11993 1 1994 11995 11996 <br /> V eachtyear aappLIC )r XXXX XXXX XXXX XXXX XXXX C 7o 10011701 1 Q �-� 5 ��/ <br /> E TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX 1 -76 1 C 1110 11 IV I I 7 L) I I I0 $ <br /> S <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 2528 <br /> T1991 through 1996 <br /> E # Tanks_(_ x 856.00 1986 through 1990 <br /> (Enter amount and year) <br /> C <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L c�p0 <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = 5 3 7 <br /> S <br /> tan Review & Inspections) I TANK I.D. #(s) <br /> U TEMPORARY CLOSURE (P <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (P(an Review & Construction Inspections)I TANK I.D. #(s) <br /> L <br /> A 5624.00 minimus $ <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE - 578.00/hour (3 hours minimm/TANK) I # TANK(s) _ X 5234.00 = <br /> AS <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br /> RS <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = 5234.00 minimum <br /> N TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I5 <br /> SS <br /> ClCONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> i <br /> TOTAL DUE <br /> :::":—SLIEEPSi tOt1PU-`(?�R LOC COOETPST CODE AMOl1NT RCclVE��HEC� CASr�—Rl~Cc'�E�E{y— 11AfE kEI:fIVED <br /> 46. <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />