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SAN JOAQUIN CalLY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAL H DIVSIOK <br /> UWjjjFCMD STORAGE TANK PROGRAM - FEE UORKSII <br /> ACILI + ITE NAME 'teaFAC ILITY CONTACT NAME rA1v—� <br /> F <br /> c FACILITY ADDRESSS1TE PHONE Z with AREA <br /> AV <br /> pTY ST TE ZIP CODE 0 of TANKS <br /> PZ&A P-- --- -- I, /at SITE -/7� C�f :IJ <br /> APPLICAN ILLING NAME APPLIC, T CONTACT MW <br /> C MAILING AOOR 5 APPLICANT PHONE # VITH AREA CODE <br /> A r � <br /> M <br /> T CITY STATE Zip CODE TYPE of APPLICATION <br /> (Closure, Inszallation, etc.) <br /> TOTAL <br /> -' 1 1986 1987 1988 1989 1990 <br /> AXNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 " <br /> A xxXX x700( S <br /> .0 <br /> T FACILITY°PENALTY',FEES ASSESSED (If Applicable) xxXx Xx7(X S <br /> I <br /> Y <br /> 5Ti1NK$FEE 9 550�00%TAZIK`' (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> � Tanlcs�:.: 1986 1987 1988 11989 11990 1991 1992 1993 1994 11995 11996 <br /> F C> ilT 0Lyjx.,try fee':for <br /> A eachiyca `applflcab(e) xxxx xxxx S <br /> V d 'pyr r,:ry.. <br /> I flYJIL'TYFEES`ASSESSED xxxx xxxx <br /> I `STATE Sl7RCARCE '= 556,00 each TANK (Due every a years) See California H 3 S Code, Section 25287 <br /> Tr.5:it..Ac L4+A�brA.a�r .q•.. <br /> Y # Tanks'' z;=,s '00 1988 through 1990 1991 through 1996 <br /> (Enter aunc;,and' <br /> moyear) <br /> ClPERMANENTtCLOSLiREI�(RemovaL or Authorized Closure-in-P(ace) I TANK J.D. V(s) <br /> L <br /> Q CLOSURE`fEEt+r S7D 00/hour (3 hours minimum/TANK) X TANK(s) x 5234.00 - S <br /> a..w. :: <br /> U "TEl4POR TCCLOSURE (Atan`Review & inspections) TANK I.D_ x(s) <br /> R y r <br /> E S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum; S <br /> P [HSI ALLATION''PLANCHECK (Plan Review $ Construction Inspections) 7ANK I.O. 16) <br /> L <br /> A <br /> X PLAN CHECK FEE.- 578.00/hour (8 hours minimum/FACILITY) - 5624.00 minimum S <br /> R REPAIR FEE {1Jarkplan?Revieti Construction Inspections) I TANK [.0. l(s) <br /> E :Win. m wna. <br /> P TANKLINING REPAIRFEC! `'S78.00/hour (3 hours minimum/TANK) TANK(s) X 6234.00 = G437c� <br /> A <br /> I TANK RETROFIT REPKIR FEE = S78.D0/hour (3 hours min./FACILITY) S234.00 minimum YIU pltlq� <br /> P-ff NC REPAIR F 3`578.00/hour (3 hours minimim/FACILITY) _ %234.00 minimum S 773(1- <br /> X TRANSFER FEE * $20.00 UNAUTHORIZED RELEASE EVALUATION 578.00/hr I 1 S <br /> S } <br /> C CONSULTATION FEE 578.00/hr SAMPLING INSPECTIONFEE = 578.00/hr S <br /> TOTAL DUE S 0 <br /> FCI -IFFICE USE OIILY <br /> '- �.+EEPS # I COMPUTER * I LOC CCOE , DIST CODE AM(7UNT RECEIVED CHECK 3/CASH 1 RECEIVED 3Y I DATE RECEIVE', <br /> a <br /> - <br /> �.� .......... <br /> EM 23 032 (REVISED 10-28-93) 3 <br />