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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIR010NEATAI "FJLLTH DIVSION <br /> N00=a.M STORAGE TANK PRCQM - FEE UJORK.. <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHONE # withAR CODE <br /> b <br /> P G� � <br /> CITY ST E ZIP CODE # of TAH <br /> � — Qcj Zc�(� et SITE � <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME �` I <br /> IV- I Ll G �riva <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N 12o 9w. 76 57- <br /> T <br /> 7T CITY STAT ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> SZ TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1987 1988 1989 1990 <br /> AIXX)0( )OW XXXX �bO /J>fJ $ Zcro <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXX)( XX)(X xxxx /o d fp p s L,00 <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 6170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1 1996 <br /> F (multiply y fee for <br /> A each year applicable) XXX)( )O= I XXXX �p sp 17n 17p r7p <br /> C r 70 = 7�fl <br /> 1 TANK PENALTY FEES ASSESSED XXX( )OOO( )OW Sv SO / 7p 17U 1 7D 17� S <br /> L <br /> I STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> T # Tanks x 156.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> s <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-P(ace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 278.00/hour (3 hours minias/TANK) # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> PINSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minium/FACILITY) = S624.00 minimum S <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 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimun/FACILITT) _ $234.00 minimum $ <br /> N TRANSFER FEE $20.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = S78.00/hr $ <br /> TOTAL DUE s 9 O <br /> - - a-- - —,- - ..=.::sem _.�••�..----•�_—_-=_-�-s-z_�= <br /> -"�GE�fi bhi�U'T>li L ' oti AHo1- C>"IVEb CHECK #IC R�CTV6Y` tiATLkr C'�l'vEfs q <br /> $ ' <br /> EH 23 032 (REVISED 4-29-94) Page 11 <br /> / n <br /> <��� �� w��L� Uri 3 ) � ��� Cu/ Yf, U«� <br />