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TH <br /> CES <br /> SAN JOAQUIN or Y LIC UNO�OUND STORAGE L TANK PRIOGRAM ENVIRONMENTAL FEEWORKSHEETHE'"H DIVISION <br /> S 7ACILITY SITE NAME FACILITY CONTACT NAME W" <br /> I c.oub,r ta-r kkAtilK�f,"cx--- NAA-RK RkN�1O <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS <br /> 17p,�( W. C P-rEE� wA y- <br /> a CITY STATE ZIP�C E at SI7Eof NKS n <br /> A C40 G ✓ !, <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L NAJ tztc RA-tJLJ I p S�ri+AC <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A P.o. �c 3o3oB 2�1 . 522, o9t32_ <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY i A aCJ y1� (Closure, s a lation etc.) <br /> o��'-oN VIr <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A %XXX XXXX %XXX %XXX X%)(X 5 X%XX%X%%X%X%X <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X%XX XXX% XXXX X%%X X%%X $ XXXXX%%%X%XXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = _� 1986 1987 1988 1989 1990 1991 1992 1993 7994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXX% XXXX XX%X XXX% XXXX S <br /> C <br /> I I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX I XXXX S <br /> L <br /> !I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> T <br /> T # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> $ Lp <br /> CPERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = 5 <br /> S <br /> Ul TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. 4(s) <br /> - <br /> it <br /> Ei TEMPORARY CLOSURE FEE = 578.00/hour (3 hours m,nimum/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (PLan Review 8 Construction Inspections) TANK I.O. #(s) <br /> L V ,OD _ <br /> NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum �1L511 3624-4 <br /> �? 15D g <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) � <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min-/FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 878.00/hour (3 hours minimum/FACILITY) = $234.00 minimum 5 <br /> M TRANSFER FEE = E20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578-00/hr S <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> `_- =:i'=.ii-`=:F_=-'.� <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH I RECEIVED BY DATE RECEIVED <br /> EELS <br /> ,*APO, 9 40W <br />