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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION -�T\ <br /> LWERGROUND STORAGE TANK PROGRAM - FEE 110RCSHEET ' <br /> ILITT SITE NAME FACILITY CONTACT NAME <br /> PHONE N with AREA CODE <br /> FACILITY ADDRESS SITE <br /> g Of LS <br /> CITY STATE ZIP CODE N of TANKS Y <br /> A at SITE 7- - 1/ oeo 6�1-[A-.+•tl <br /> L J <br /> P APPLICANT CONTACT NAME <br /> PAPDL ICANT/BILLING NAME <br /> I IIIN D`DgRE55 APPLICANT PHONE N WITH AREA CODE <br /> A 5-0 zay - �y-8333 <br /> a I STATE ZIP CODE TYPE of APPLICATION <br /> T CITY (Closure, InstallatlOn, ate.) <br /> �� ,J SZ <br /> STS TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FO tori J lT!` �00.00 S <br /> A <br /> C x%%X xxxx S <br /> T FACILITY PENALTY FEES ASSESSED (If Applicebl <br /> 1 (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> V TANK FEE • 550.00/TANK <br /> EN Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> + <br /> F (multiply N by fee for ! <br /> A each year applicable) <br /> C <br /> I TANK PENALTY FEES ASSESSED xx%% %X%% <br /> L <br /> 1 STATE SURCHARGE + $56.00 each TANK (Due !very 5 years) Sae California N 6 S Code, Section 25287 <br /> r1991 through 1996 <br /> Y M Tanks m SS6.De 19" through 1900 <br /> (Enter amount end year) S <br /> PERMANENT CLOSURE (Remove! or Authorized Closure-inr Pl gee) TANK I.D. /(s) <br /> LN TANK(9)_L% Z,X $234.00 <br /> 0 CLOSURE FEE • $78-00/hour (3 hours minirmMTANK) <br /> STANK I.D. N(a) <br /> U TEMPORARY CLOSURE (Plan Review It Inspections) <br /> 0. <br /> E TEMPORARY CLOSURE FEE • $78.00/hour (3 hours minimsn/TANK) M TANK(s)_ % $23 + <br /> P INSTALLATION PLAN CHECK (Plan Review t Construction Inspections) TANK I.D. JIM <br /> L <br /> A + $624.00 minimum $ <br /> N PLAN CHECK FEE • $78.00/hour (8 hours minlnAAn/FACILITY) <br /> R REPAIR FEE (Workplan Review L Construction inspect 101e) <br /> TANK I.D. N(a) <br /> E <br /> P TANK LINING REPAIR FEE • 578.00/hour (3 hours minimum/ N TANK(s) X f23L.00 S <br /> A <br /> I TANK RETROFIT REPAIR FEE • $78.00/hour (3 hours min./FACILITY) $234.00 minimum <br /> S <br /> 0. • $234.00 minimum <br /> PIPING REPAIR FEE + $78.00/hour (3 hours minimum/fACiLiTY) <br /> M TRANSFER FEE + $20.00 <br /> UNAUTHORIZED RELEASE EVALUATION A 578.001hr S <br /> 1 <br /> S + $78.00/hr $ ! <br /> C CONSULTATION FEE $78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE $ <br /> .A OFFICE USE ONLY <br /> mnw'nm <br /> SUEEPS N COMPUTER N LOC CODE DIST CODE AMOUNT RECEIVED CHECK CASH ECEIVED BY GATE RECEIV <br /> a f <br /> EH 23 032 (REVISED 11-1-92) ` <br /> Page 11 CZ_4.//o, A �� <br />