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SAN JOAQUIN CO' ISLIC HEALTH SERVICES - E)IMMOINIMAL NET OIVSIOM <br /> AML .RQUNO STORAGE TASK PROGRAM - FEE WMESSID-1: <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1F-,T r <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> _ <br /> L STATE ZIP CODE # of.TANKS <br /> A CITY at SITE <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/11ILLING MANE I� <br /> L <br /> I PLICANT PHONE # WITH AREA CODE <br /> C HAILING ADDRESS <br /> ') Ce <br /> y 2. 0 Su � ��v z a 7 IS <br /> T CITY STATE ZIP CODE APPLICATION <br /> ACI P N C v A C h S`� 42 (Ctosure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1198E 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • 5100.00 XX)IX 7000 100IX 100a S 700000001 <br /> A <br /> C170(70( XXXX 7000( X700t J 0001 5 70000000( <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) <br /> I 1,7997) 5170/TANK (After January 1, 1991) <br /> V TANK FEE • 550.00/TANK (Prior to Jarwry <br /> E <br /> 9 Tanks � 1988 1989 1990 7997 1992 17993 11990 1995 I )996 11997 1998 <br /> F (aultiply # by tee for I I S <br /> A each year applicable) 7000( =a 70001 )OOIX 7000( <br /> C S <br /> I TANK PENALTY FEES ASSESSED I X%7(X XX70( X1001 11000( 1000( ( I I <br /> L S <br /> I STATE SURCHARGE FOR NEW FACILITIES OULY•SIS-50 <br /> T <br /> Y # Tanks_ X 58.00 1988 tl7rougNN 1993 CSS b) 1993 C717.O119Ni 1997 (S56) 1 <br /> S <br /> SURCHARGE FOR 1998 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. MKS) <br /> LI f TANK(s)!> X 504.00 • S <br /> 0 CLOSURE FEE - 578.00/hour (3 hours miniaLPITANK) <br /> STANK I.O. #(s) <br /> U TEMPORARY CLOSURE (Plan Revive L Inspections) <br /> RS <br /> E TEMPORARY CLOSURE FEE • S78.00/hour (3 hours minimus/FACILITY) 5734.00 miniattn <br /> P INSTALLATION PLAN CHECK (Plan Review d Construction Inspections)( TANK 7.0. 7T(s) <br /> L <br /> A : 5624.00 minim= S <br /> N PLAN CHECK FEE = 578.00/hour (3 hours minimum/FACT LI TY) <br /> R REPAIR FEE (Workplan Review L Construction Inspections) I TANK I.D. #(s) <br /> E5 <br /> P TANK LINING REPAIR FEE • SIM.00/hour (3 hours mininm(TANK) # TANK(s) _ X 5234.00 <br /> A : $234.00 mini" <br /> S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br /> R 5 UU <br /> PIPING REPAIR FEE = SM.00/hour (3 hours minimua/FACILIT7) • $234.00 minimum <br /> N TRANSFER FEE * $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I I S <br /> ClCONSULTATION FEE = s78.00/hr I SAMPLING INSPECTION FEE • 578.00/hr00 <br /> I S <br /> (v P7 AAa �Ci�-cam �A a-3Cja tom. a ` i TOTAL DUE 5 <br /> FOR OFFICE USE ONLY <br /> �� <br /> ;y SHEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK 2l/CASH RECEIVED BY i DATE REMIVED <br /> s <br />