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SAN JOAQUINPUBLIC HEALTH SERVICES - MIROIRdTILL D)VSION <br /> GROUND STORAGE TANK PROGRAM - FEE YORK <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> s lc( 5 - Sok 11c, v —YG — 31S-(� <br /> CITY �v L / STATE ZIP CODE # of TANKS <br /> V J�-U Gr ' M �/S ZJ (e at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> 1 uk Cvf <br /> C MAILING ADDRESS / APPLICANT PHONE # WITH AREA CODE <br /> N <br /> T CITY _ STATE ZIP CODE TYPE of APPLICATION of <br /> Fre rJ,.�� [ YS3J, (Closure, Installa ion, etc.) vin xaD(ow v�ei <br /> 1 <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A xxxx XXXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX Xxxx s <br /> L <br /> 1 STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California N 8 S Code, Section 25287 <br /> T <br /> T # Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = s <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = s <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minim n/FACILITY) _ $624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) K 5234.00 = s <br /> A <br /> I TANK RETR EE _ $78.00/hour (3 hPurs min./FACILITY) = $234.00 minimum S <br /> R <br /> PI G REPAIR FEE = $ /hour (3 hinimm/FACILITY) = $234.00 minimum S <br /> M T NSFER FEE _ $20.0 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr s U� <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE - S78.00/hr $ <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> .......... :!eam:: :::::,!-:_t:!::!::.................:::::a::na::_:�::::!! ......�.:..._...,____................-:..._._.........—_............... .....:..._:................_..........:..__....�::_................:_.._..__......._.:_ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> x'3/0 v 9 <br /> vg2gtI_ u/ 3 J-3 s ' <br /> ...._......_.._...._...._.. � Gun_a�' 9_ ::__ n:!!:n!e:::n <br /> EH 23 032 (REVISED 6-21-93) Pae 11 • <br />