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K�2 <br /> SAN JOAQUIN fYXAfTY PUBLIC WEALTH SERVICES - ENVIROWFCNT/` LALIN DIVSION <br /> ERGROl11D STORAGE TANK PROGRAM - FEF. UCRKS -6E NAME <br /> FACILITY CONTACT NAMERESSSITE PHONE N With ARE CODE <br /> `/W � V/C i x / C4) 33Lr STATE ZIP CODE M of TANKS <br /> P — CA LC> at SITE <br /> P AAPPL�IyCA�NT/BILLING NAME APPLICANT CONTACT NAME <br /> C MAILING ADORES <br /> S APPLICANT PHONE N WITH AREA CODE <br /> EN plo -. 3� v los Yc <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> C14 Isz/ (Closure, Installation, etc.) <br /> OTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100,00 1986 19871988 1989 1990 <br /> A <br /> C XXXX XXXX 5 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX <br /> I S <br /> V TANK FEE 150.00/TANK (Prior to January 1,1991) <br /> E 5170/TANK (After January 1, 1991) <br /> I Tanks = 1986 1987 19881989 1990 1991 <br /> M by 1992 1993 1994 )995 1906 <br /> F (multiply lee for <br /> ArTANK <br /> ear applicable) XXXX XXXX <br /> C f --- <br /> tENALTY FEES ASSESSED XXXX XXXX <br /> L1SURCHARGE - 556.00 each TANK (Due every 5 years) See California H 5 S Code, Section 25287 <br /> 1s_ x 556.00 1988 through 1990 <br /> r (Enter amount and year) 199t through 1996 <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(a) <br /> L <br /> 0 'CLOSURE FEE--. !78.00/hour (3 hours minimum/TANK) M TANK(s) X 5234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review L inspections) <br /> R TANK I.D. f(a) <br /> E TEMPORARY CLOSURE FEE • 578.00/hour (3 hours minimum/YANK) M TANK(s)__ X $234.00 <br /> S <br /> P INSTALLATION PLAN CHECK (Plan Review L Construction Inspections) TANK I.D. R(s) <br /> L <br /> A <br /> M PLAN CHECK FEE a (78.00/hour (8 hours minimum/FACILITY) = 5624-00 minimum <br /> S <br /> R REPAIR FEE (Workplan Review d Construction Inspections) TANK ID. M(s) <br /> E <br /> P TANK LINING REPAIR FEE 278.00/hour (3 hours mininam/TANK) M TANK(s) X 5234.00 = <br /> A f <br /> 1 TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) . 5234.00 minfmun <br /> 4 5 <br /> PIPING REPAIR FEE 578.00/hour (3 hours minlmlm/FACILITY) n 5234-00 minimum <br /> f <br /> N TRANSFER FEE • $20.00 UNAUTHORIZED RELEASE EVALUATION = f78-00/hr <br /> I 5 <br /> S <br /> C CONSULTATION TEE 278.00/hr SAMPLING INSPECTION FEE 578.00/hr <br /> S <br /> TOTAL DUE S <br /> AOR OFFICE USE ONLY 3 <br /> ,'°"!?'IWii!^1N!!6!gP.!!I!i!9l111!il!9aC91!'..M.^.mAl!II!!IRCnnm!mn!il!11!n!n!I!!i!ileo!tilii!ng!In!!!!!!yn!6!i!C^Imm�!Iggr nnrrr.r nrnr n-nrn <br /> S,a ar::.4.._uS.4W9LEAE:1P14SX94N!IfIiWi1111111111!II!I!IIIIIWIIin1111WIii!ILILILn11111ii1@IIIIIr!111!IILILmiii!iii!illiii!!i.!!!!!i!!I!II!i111n!i!!i[i!igIrPI.Ir.I.'r.i�ILn.r C11n.v.v:.l..iLnn.r.°..: . .v.....0....1r.rnn <br /> 1u11l!1!1m1m!In!i.,illril!n..1l!r.1r1.m.!!.!.n.I.lri.i!Ia..II!li!n.I.!n.1.e.............. <br /> COMPUTER X LOC CODE ... ...n.n <br /> DIST CODE AMOUNT RECEIVED CHECK X/CASHRECEIVED <br /> !I!nIr1,�nil!niln�nl!IrIIm!ImIII�IInIIIIIr'nI'llI II,IMXINIIIIi�li�llil'�I Ii11�111i�l,i <br /> iT <br /> RE CEIVEO BY DATE RECEIVED !u <br /> !n 5 5 <br /> 15!9..........!!!Eiin:iPS!n1ii1!!!I_!11!nl':P n <br /> ' (L.rin_n!ntW!amu:e!mm�gn!nn!!.^.Itanu.mv!Wgnnn!uaurxlnnm!�Ilu!�!Icuc!icl�a!n!!nmlmml•rr!n r !n <br /> -.. <br /> -���^-:--�.:.LI!!eplArlmiii!YllmhallWlllllLllilJalNY..almWlar.la11111.InIIInlLllll.InILiII11L.ILILiILI.+I.I!li�l!II!!L!il!1111111!Iliilei!I!:!ILnaII:LI!Illi!ill!II!n�^m n: '�r r n r I i.nnr^°.1111-n?-!!Inlnl!rinll!I!IIW!!!nn!nL'nl!n!Wllll:n!1 n r. r,,,.,� <br /> '�"'�'-�"""r-""""-'' ......I..Il.lirl.l.l,1..1111.111111111111,11111111111111!I!I!rIlI11J!I!Ilii(I!lil!II!III!Illlli�illi!Iliil!!!!I!II!I!I!IIIIII'!I I'II IIIJIIii� <br /> EH 23 032 (REVISED 6-21.93) Page 11 <br />