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SAN JOAQUIN CCUNTT�L IC HEALTH SERVICES - ENVIRONMENTAL NFJLLTL�/SION <br /> UIDERGRMW STORAGE TANK PROGRAM - FEE W0RKSREET <br /> I S' FACILITY SItE ANE FAC ITV CONTA HANE ' <br /> 1 I Zc L7 <br /> ACILIIY ADDRESS 9T, NE / with AREA CODE <br /> '- Z > <br /> I (Try STATE ZIP C / 01 TAMKS <br /> PI. LDC GTO �'+q'' lbi at SITE <br /> P nvFl(CANT/BILLING NAME APPLICANT COIITACT E <br /> 67 %7lr C�? C <br /> I: MAJ//✓1,,I NG ADD SS APPLICANT PHONE R VITH AREA CODE <br /> r CI Iy STAT CODE TYPE of APPLICATION` <br /> (Closure, Installation, etc.) . �`.. . <br /> i <br /> TOTAL <br /> 1989 1990 <br /> ANIIUAL FACILITY FEE (Prior to January 1, 1991) • 5100.00 1986 1987 1988 <br /> A 5 <br /> C <br /> F FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E - <br /> Y Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1 1995 1 1996 <br /> F1 (nmA tiply s by fee for <br /> A such year applicable) 5 <br /> C "'— <br /> I TAI4K PENALTY FEES ASSESSED KXXX xxxx S <br /> l I <br /> II t1ATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 6 8 Code, Section 25287 <br /> Y t ranks x 256.00 1986 through 1990 1991 through 1996 <br /> (linter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(a) ^b <br /> n CLOSURE FEE = S78.00/hour (3 hours minimum(TANK) R TANK(s) IT $234.00 - IOU <br /> It TEMPORARY CLOSURE (Plan Review 6 Inspections) TANK I.D. #(a) g0tl <br /> R .__.._- <br /> 1. TEMPORARY CLOSURE FEE _ 178.00/hour (3 hours minimum/TANK) N TANK(s) X $234.00 - S �— <br /> P INSTALLATION PLAN CHECK (Plan Review S Construction Inspections) TANK I.O. S(a) <br /> A <br /> N Pt.AN CHECK FEE - 578.00/hour (8 hours minima/FACILITY) 5624.00 minima S a_ <br /> R -REPAIR FEE (Workplan Review L Construction Inspections) TANK I.D. N(a) <br /> P TANK LINING REPAIR FEE - 578.00/hour (3 hours minimm/TANK) R IANK(s) X $234.00 = S <br /> A -"— <br /> YAIIK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = S234.00 minimum 5 <br /> R <br /> PIPING REPAIR FEE 578.00/hour (3 hours minimm/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE $20.00 UNAUTHORIZED RELEASE EVALUATION - S78.00/hr 5 <br /> I <br /> C COISULIATION FEE = 578.00/hr SAMPLING INSPECTION FEE - S78.00/hr 5 <br /> TOTAL DUE S7--314 ro <br /> ( ?I'FICE USE ONLY <br /> sl!::;a!!u!mar!ns!!:esmn:.mwl^euros w!!ae:am!n:ra!wim;wxummnawnmsm!wnm!a an nmxmmm�aminm;esmmmlmnnw!.0 I !n!!mnnmannmmn!mm!m!mmlr_vnen:mc:-wn:!.=.!nnw:�aw::ms!ar_!n:!!!;!:!, <br /> :::ppa:!!m;ar•aaa:!::+cu!:!s!A;lalww!w;mmunn!:mraan!n!ul!n!!vuwwu°�Iwewuwwslwnnceoeuwnu!cllmm�lnm�ia!i�iu!!!mw�u�!wn;ww!omr!!acus:mm;uwnmuu!wu!wuu;a!m:r;a!_::;rc:nss:;ar;:F!!!!v! <br /> ... 5_L.vhtlrh : I <br /> L..EPS s I COMPUTER N LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK //CASH I RECEIVED BY I DATE RECEIVED <br /> Ifl 5 <br /> :.—:lL_:C!1!11::!Un!!!ill!!::! !Imnlnnln c!!:m nCI!alm!ma.m H.m.lunl lm n m mlllll. .!R nm n !X _nn IIaTJnll11�!Xnllllllml!11.!IIII!I1!11:1!m1mra_!" ! ! <br /> .. :. :_!me.-.=IFI mil-ii mann mai u:u,mwulww!m!!�m!i!Ta:O MIRILINHIM!!ri�nlh!�'w;�"ui"u�mmn'u�'I!u!i�i l"�"vlH199%�"u�u!"Pin ll!Pi�um!I�mi��iu�"i!Iwu mnlTi��!,ul:lnl,n. .un!:I ! <br /> In .'! 032 (REVISED 11-1-92) Page 11 <br />