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,v SAN JOAOUIN CP Y PUBLIC HEALTH SERVICES - ENVIRQM ENTAL HT 'H DIVSIOSN <br /> --2OAO STORAGE TANK PROGRAM - FEE WORK <br /> S FACILITY SITE NAME <br /> 1 it �i��� FACILITY CONTACT NAME <br /> EI FACILITY ADDRESS !'/Y"'� <br /> a <br /> 2 iG Q/a f� ST SITE PHONE M With AREA CCOE <br /> CITY <br /> A f p�" STATE ZIP CODE X of TANKS <br /> P // 4-4 �5z y� at SITE <br /> P APPLICANT/BILLING��I,N,,G11 NAME <br /> I 1AA c-f /°��GG APPLICANT CONTACT NAME <br /> C NAILING ADDRESS <br /> A / F/ ^ APPLIGM PHONE f WITH AREA CODE <br /> " � ZZz -8zio <br /> T CITY r- ST TE ZtP CODE TYPE of APPLICATION <br /> r✓�cs, v <br /> `�j70<i (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to Jarwary 1, 1991) = 5100.00 1986 11987 11988 1989 1990 <br /> A <br /> C. xxxx xxxx /DD 5 3�v <br /> T FACTL[TY PENALTY FEES ASSE ED (1 A to <br /> I XXX)( uxx rOJ !DJ I /00 S 'ADO <br /> V TANK FEE = S50.00/TANK rio J ry 1 17 5170/TANK (After Jarwary 1, tggl) <br /> E <br /> S Tanks = I 1986 1987 <br /> F (nultiPLY 7-;Y--f" for 1988 1989 1990 1991 1992 11993 1994 1995 11996 <br /> A each year applicable) I XX)(X XXX)( t> <br /> C O so 14l p 7(,,- r 70 t 7D S b/� <br /> b 4f) <br /> I TANK PENALTY FEES ASS'eSSED %XXX I xxxx 150 SJ I SD / 7 L7If 7 J 17Q <br /> L <br /> ! STATE SURCHARGE = &56.00 each TANK (Due every 5 years) <br /> T See California H a S Code, Section 25287 CrJb <br /> Y 3 Tanks ( x 556.00 I 1988 through 1990 <br /> (Enter amount and year) 1991 through 1996 <br /> �� Pd <br /> Es = <br /> L, <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. R(s) <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minieam/TANK) ; TANK(s) ( 5234.00 = <br /> S po f <br /> U TEMPORARY CLOSURE (Plan Revie a Inspections) / <br /> R TANK I.O. 4(s) <br /> Ej TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimam/TANK) N TANK(s)_ X !234.00 = <br /> S <br /> PI INSTALLATION PLAN CHECK (Ptan RevieM a Construction Inspections)I TANK I.D. #(a)L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours miniimm/FACILITY) <br /> 5624.00 minimum 5 <br /> R REPAIR FEE (Workp(an Review a Construction Inspectiorss) TANK L0. Y(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) k TANK(s) X &234.00 <br /> A f <br /> I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) _ !234.00 minimam <br /> R f <br /> PIPING REPAIR FEE _ !78.00/hour (3 hours minimum/FACILITY) <br /> -------------- <br /> $234.00 minimw f <br /> M1 TRANSFER FEE _ !20.00 I UNAUTHORIZED RELEASE EVALUATION = !78.00/hr <br /> I f <br /> S <br /> Cl CCNSULTATIOM FEE = S78.00/hr SAMPLING INSPECTION FEE _ &78.00/hr <br /> S <br /> TOTAL DIE S <br /> FOR OFFICE USE ONLY <br /> s SWEEPS 3 COMPUTER d LOC CCOEDIST MOE AMOUNT RECEIVED CHECK ;0/CASH RECEIVED 3Y <br /> DATE RECEIVED <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />