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S%�JOAQUIN COUNTY PUBLIC HEALTH SERVI - <br /> EWMONMENTAL HEALTH DIVISION `../ <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKcfum <br /> S F ILITY SITE NAM <br /> T O ,� p„g$�� /.^ F ILITY. TACT NAME <br /> E <br /> FA ILI RESS 1•� l.0 IG.C?y PHONE AREA <br /> r5 3r u D2. �o <br /> P CITY TE ZIP CODE # of TANKS <br /> VAN <br /> k at SITE <br /> i APPLICANT/BILLING NAME APPLICANT TA T NAME <br /> I rc.�ruil <br /> C MAILING ADORES APPLICANT PHOJ�E6 WITH ARETil , 2O1 5TCIT ATE Z CODE TYPE of APPLICATION(Closure, Installat <br /> TOTAL <br /> A <br /> C TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> T # Tanks = 1986 1987 1988 191990 1991 1992 1993 1994 1995 1996 <br /> [ (multiply W-57-fee for 89 <br /> V <br /> E each year applicable) Xxxx XXXX XXXX XXXX XXXX S <br /> S TANK PENALTY FEES ASSESSED Xxxx XXXX XXXX XXXX xxxx S <br /> T STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> E # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 878.00/hour (3 hours minimum/TANK) # TANK(s) X S234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) I <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum 3 <br /> PI INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> A TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum 3 <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimm/FACILITY) = $234.00 minimum S <br /> MI I <br /> TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> S <br /> C CONSULTATION FEE - S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr 5 <br /> TOTAL DUE <br /> .:.._._..----.—,...----`--- <br /> -if Re <br /> =-'_ __:=-:_-- <br /> i SuEEPs a`-COMPUTER # �itlt-caDE �DtsT CtXSE"""�AkIbUNT REcEtVEb�CAEt�#1'CTsii`rr'Re VV915 89-J'-- CFKfE-RECVV"ED A <br /> { u <br /> w:mmmmrtnrx�W <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />