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'JOAQUIN COUNTY PUBLIC HEALTH SERV- <br /> ENVIRONMENTAL mSTORAGEG NT.4`�NK PR GRAM SFEE w0rL5HFET. <br /> S F IL17Y SITE NAM ^A <br /> T 5S �I,(g$�� W FACILITY CT NAME <br /> 3 FA <br /> ,I`15 F R <br /> ESS <br /> CL • <br /> ITE PRONE # with AREA CODE <br /> CITY �� S;5-6�}O-6 <br /> A STATE - ZIP CODE # of TANKS <br /> P APPLICANT/BILLING NAME at SITE <br /> L AP CANT TA T(NAME <br /> I A M <br /> C MAILING ADORES <br /> A 4{A APPLICANT PH EE # WITH AREA CODE <br /> T CIT / �jATEZ CODE TYPE of APPLICATION <br /> aStO (/tt1�+� <br /> FtJS7Y5( (Closure, Installation, etc.) <br /> TOTAL <br /> A TANK FEE 550.00/TANK (Prior to January 1,1991) K (After January 1, 1991) <br /> C <br /> T # Tanks = 1986 1987 1988 1989 1990jj# <br /> 92 1993 1994 1995 19% <br /> I (multiply fir fee for �• 3'{I <br /> E each year app Icahle) XXXX XXXX XXXX XXXX XXXX (�U (�v (' S (p c�C <br /> ES TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX J(XXX ( U (-�� ` (�Q S (U�,U <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California X ; S Cade, Section 25287 <br /> T <br /> E # ranks—?b. 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> Ict <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 0 CLOSURE FEE = S78.00/hour (3 hours mini=m/TANK) # TANK sl X 5234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.O. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum s <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimm/FACILITY) = S234.00 minimum S <br /> M TRANSFER FEE = E20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> t <br /> S <br /> C CONSULTATION FEE f=� 578.00/hr SAMPLING INSPECTION FEE - S78.00/hr 5 <br /> TOTAL DUE Z5y <br /> LAA-6 QJ� 1cn I cs ,sG <br /> F..(7R,.O.EEICE_USE_O.N.LT _ <br /> .—, -----._-- -taw <br /> bnPU'T1;R —6c G'oDE- lg'T-Cb8 -cuNT�iE�ETVED- NEcX dTCTsiI— �E'CEI9�EIS3Y tia- 9SC8'IWD q <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />