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ICES - <br /> TAL <br /> SAN JOAWIN *YGRPUBLIC S-TORAGEHTANKVPROGRAME-FEE YORNKSHE&H DIVSION <br /> S FACILITY SITE NAME\ �1 C VC. 4I A FACILITY CONTACT NAME �I p 3873 <br /> I L� K <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS <br /> & STATE ZIP CODE # of TANKS <br /> CITY at SITE <br /> A J/ <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> NSTATE ZIP CODE TYPE of APPLICATION <br /> T CITY (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 XXXX X%XX 5 <br /> A <br /> C Xxx% xxxx E <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I 5170/TANK (After January 1, 1991) <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) <br /> X E 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> # Tanks = <br /> F (multiplyi� y�yfee for E <br /> A each year applicabLe) xxxx XXXX <br /> C <br /> $ <br /> I TANK PENALTY FEES ASSESSED xxxx XXxX <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25 <br /> T1991 through 1996 <br /> Y # Tanks ('o x $56.00 1 1986 through 1990 <br /> (Enter amount and year) ,3 6 3 6 E T Z <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L # TANK(s) /- x $234.00 = =3Y. <br /> O CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /> S TANK I.D. #(s) ROIU TEMPORARY CLOSURE (Plan Review & Inspections) qR aJ <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) �Ipa <br /> L <br /> A $ <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimus <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) _ X $234.00 = <br /> A $ <br /> 1 TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = 5234.00 mini <br /> RE <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mi nimun/FACILITY) = $234.00 minimum <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> 1 <br /> S E <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br /> TOTAL DUE $ ' <br /> ......::::::::::�::::::: <br /> CE USE ONLY .................................... ................................ __ <br /> OR OFf ................ ................. ........................................................................._...:..:::::::::::::: ::::::::::::::::::::::::::::: ::: : ::::::::::::tt:::::::::: <br /> SWEEPS # "COMPu'YER # LOC toOE" OISY CODE Iii"EiHeCkii OAT$ RECEIVED <br /> :: ......_._.........................___.._......:.................................................................iii <br /> EH 23 032 (REVISED 10-28-93) T Page 11 <br /> Pq 1'MEN 23 -190 <br /> RECEIVE6 <br /> MAR 10 1994 <br /> SAN PUKIC WEALTH COUNTY CES <br /> ENVIRONMENTAL HEALTH DIVISION <br />