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ah <br /> SAN JDAOUIN COI' PtB-__ HEALTH SERVICES - BMIRORMEATAL HEr-H D 711 <br /> Uio AM= STORAGE TANK PROGRAM - FEE Lam; <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1o (� <br /> T <br />'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of-TANKS <br /> A 57 O L at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> C MAILING ADDRESS PLICANT PHONE # WITH AREA CODE <br /> A <br /> T CITY STIA�TE ZIP CODE APPLICATION <br /> Nc \j 4 2 <br /> C 1� rj (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 11988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A )XXX xxxX )O= XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX XX)OR )O= xXXX noa S xX)OIXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After JanuarY 1, 1991) <br /> E <br /> # Tanks = 1988 I 1989 1990 1991 11992 11993 1994 1995 11996 11997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX S <br /> C 11 <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX I =(X I )0(XX XXXX I I I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 5 <br /> T <br /> T # Tanks x 58.00 1988 through 1993 (3567 1993 through 1997 (356) 1998 <br /> SURCHARGE FOR 1998 xxxxxxXXXXXXX)(XXXXX)DOW(X)OC XXXXX)OOQOQOQO(XXX)Q000(X S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I k TANK(s) 2 X 504.00 = 57 <br /> S <br /> U TEMPORARY CLOSURE Celan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE 578.00/hour (3 hours minioam/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.O. #(s) <br /> L <br /> A = 5624.00 minimum S <br /> N PLAN CHECK FEE = S78.001hour (8 hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) 0 TANK(s) x $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R p <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimus S U <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I I I 1 <br /> S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED I CHECK x/CASH RECEIVED BY DATE RECEIVED <br /> z <br /> 77 <br /> cu iZ nv) (RFVTSFO 1-12-98) PLA-( `I <br />