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+ SAN JOAOUIN PUBLIC HEALTH SERVICES - ENVIRONME)ITAL TH DIVSION <br /> II I R?G,ZOU1NIO STORAGE TANK PROG1RAX - FEE LORKSH <br /> T FACILITY SITE <br /> �M�-rn� �VNC KfN YCfTL1 N �q clllt� FACILITY <br /> 14 ?,,t 55o <br /> 'E FACILITY ADDRESS 1 SITE PHONE : with AREA CODE <br /> d <br /> 4o, SaNI1 LIVlc.oIm SP 2- 09 — L} b V—,519 7— <br /> CITY STATE ZIP ZIP CODE N' Of TANKS <br /> A S�c-�T �+h CA g5Zo aJ I at SITE <br /> P <br /> PAPPLI ANT/BILLING N ME APPLICANT CONTACT NAME <br /> C MAILING ADDRESS APPLICANT PHONE : WITH AREA CODE <br /> A 1145 W. c( cly v Wq• <br /> N zo9 — 4 t, L. —51°) 2 <br /> T CITY I STATE ZIP CODE TYPE of APPLICATION <br /> SI-+C�e�17vI CA g57-o3 I (Closure, Installation, etc.) CIOSVVU <br /> TOTAL <br /> I 1 I I <br /> ANNUAL FACILITY FEE (Prior ;o January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> A I %XXX I %%XX I XXXX I %%XX I X%XX 1 S Xxxxxxxx <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I Xxxx I XXXX I x%Xz XXx% I %%%X I S zXXX%%%% <br /> 1 <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E <br /> Tanks = 1988 mg 1990 1991 1992 19911 199; 11995 11996 11997 <br /> F (mut;iply ' „y fee for I <br /> A each year applicable) XXXX I %XXX I XXXX I XZXX Ixzx% I ) I /�I �I 701 /"why e-,;` g v� <br /> I TANK PENALTY FEES ASSESSED I XXX% <br /> L I bdnj r%%XX I XX%X I %XXX 1XXxX I 1 �1�I /701170 1/70 --`` S Uy)�) <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 I S <br /> T <br /> T d Tanks x 58.00 1988 through 1993 (S56) :993 through 1997 (S56)!`j <br /> SURCHARGE FOR 1998 %X%XXXX%XXX%XXXXX%XX%X%%XXX XXXXXXXXXXXXXX%XXXXXXX% I S <br /> LI PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK 1.0. =(s) <br /> 1 011CLOSURE FES = 578.00/hour (3 hours mini:ua/TANK) I ; TANK(s)—� X 5234.00 = I s <br /> S <br /> IITEMPO7.AP.Y CLOSURE (Plan Review d Inspec;ions) i TANK 1.0. C(5) I <br /> R i <br /> EI TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minims,/FAC:LITT) I 5234.00 mini nra 15 <br /> P iNSTALLATION PLAN CHECK (Plan Review d Construction :nspec;ions)I TANK I.D. :(s) 1 <br /> L <br /> A <br /> N PLAN CHECK Fc = 578.00/hour IS hours minim s/FACILITY) = 1624.00 minio. 5 <br /> RI REPAIR FEE (Workplan Review d ConsLruc;ion Ins pec ions) I TANK 1.0. :(s) <br /> E( <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minioun/TANK) I 1 TANK(s) X 5234.00 = I S <br /> A <br /> I - TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimi l S <br /> 2 <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minim. /FACILITY) = SZ34.00 minim , S <br /> i <br /> M TRANSFER FEE = 520.00 I I UNAUTHORIZED RELEASE EVALUATION = S78./0/hr I I S 1 <br /> I 1 <br /> S 1 I <br /> C1 CONSULTATION FEE 578.00/hr I SAMPLING IHSPECTICN FEE = 578.00/hr I I S 1 <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY -7 z <br /> - 2v(gb <br /> T _ _ — <br /> a <br /> SWEEPS 1 i COMPUTER X 1 LOC COCE 1 DIST CODE AMQINT RECEIVED CNE :/CASH 1 RECEIVED BY 1 DATE RECEIVED <br /> --- __ — _ <br /> E4 71 n17 IRFV)SFO 1-12-98) <br />