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IROM <br /> SAN JOADUIN IAO IERGR�$ 7HEALTH <br /> TANK SERVICCEESPROG - EwVFE 110RNIAL WEALTH �ON <br /> . ...._.— ET <br /> FACILITY CONTACT NAME <br /> Si fA(IILITY SI,E NAME • BOJ <br /> - �{ — SITE PHONE / with AREA CODE , <br /> nC y.l I1 A OR <br /> 5 ?�StGl�r�C E y <br /> IT i! ZIP CODE $ of TANK! _ 1! <br /> 1 I IY O at SITE <br /> �jY}W-+J <br /> I• — APPLICANT CONTACT NAME <br /> I` APFLICANT/BILLIMG NAME A/S' <br /> APPLICANT PHONE $ WITH AREA CODE <br /> I <br /> oil IIID AD C% — • — <br /> N �-'—� V fi T! 21P COO! 1 TYPE of APPLICATION <br /> I F.IIY -� (Cloture, Installatlon, etc. 1 <br /> D(� 7 TOTAL <br /> .•— 1986 1967 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • !100.00 S <br /> A <br /> I "Cl IL IIY PENALTY FEES ASSESSED (If Applicable) <br /> I ----- !170/TANK (After January 1, 1991) <br /> V fF.IIK FEE _ $50.00/TA4K (Prior to January 1,1991) I- <br /> F 1986 1987 1988 1989 1990 1991 1992 1093 1094 1995 1996 <br /> I Tanks <br /> I (nwltlpty N py fee for f <br /> A cnrh year applicable) _ <br /> I TANK PENALtY FEES ASSESSED %%%% %K%% <br /> I ;FATE SURCHARGE • $56.00 each TANK (Due every S yaerq fee Cellfornls X i f Coda, Section 25287 <br /> T e fenks__ A 156.01 <br /> 1986 through 1990 1991 through 1996 <br /> (I:nter smoul: end year) f <br /> l' PERMANENT CLOSURE (Removal or Authorized Closure-In-Place] TANK I.D. $(a) <br /> I ..._ / TANK(s) Z % !234.00 • ! <br /> 0 r.I.OSURE FEE • $78.00/hour (3 hours Tal nlpam/TANK) <br /> u IrMPORARY CLOSURE (Plen Review f Inspactione) <br /> TANK I.D. $(t) <br /> P - t <br /> I IFMPORARY CLOSURE FEE • f78.00/hour (3 houri IAInIImMTANK) / TANK(s)_ % !234.00 <br /> p...INSfALLAT ION PLAN CHECK (Plan Review $ Constructlon Inspectlons) YANK I.D. f(q <br /> 1 - <br /> A • $624.00 mini" S <br /> n VIAN CHECK FEE • %78.00/hour (8 hours minllmm/FACILIYY) <br /> P -PF.PAIR FEE (Workplan Review $ Cone <br /> truetlon Inepectlonq <br /> TANK I.D. f(a) <br /> P IANK LINING REPAIR FEE • $78.00/hour (3 hours minlmlm/TANK) f TANK(U % (234.00 <br /> S <br /> A -_.—.__-__.— <br /> r (3 hours min./FACILITY) f234.00 ■inlaAm <br /> R --— . $234.00 minimae f <br /> I,11'1IIG REPAIR FEE $78.00/hour (3 hour$ minimm/FACILITY) ti <br /> M nInNSFEq F <br /> EE <br /> EASE EVALUATION a $78.00/hr f <br /> 1 <br /> — — a $78.00/hrI:ptis11L1ATION FE! o0 <br /> _. _ - TOTAL DUE f G l� <br /> 1 04 E ICE USE ONLY mamin!naI m I I <br /> �����IImm111L41111 r11"VIr I111VII <br /> I I'".i"'EM11121"m"m" 12RISIXI"m11� <br /> S�'EPS N COMPUTER N LOC CODE DIST CODE AMOUNT RECl IVED CHECK $/CASH RECEIVED BY GATE RECEIVED <br /> �_�: � Ln�I"II""u"r"uu"""IrJm mu"uuI"11"mmaallmm"��urlm�l�mu' u"Im <br /> Page 11 <br /> tN !7 032 (REVISED 71.1.92) • • <br />