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SAN JOAQUIN CC' 'r7 PUBLIC HEALTH SERVICES - ENvIRONMIENTAL H. )Ei a vsiOM i <br /> f I I1.*,,,GRaXO STORAGE TANK PROGRAM - FEE WR1G51fEE <br /> S FA ITY S[TE NAME ii <br /> IR I FACI ITY CONTACT NAME <br /> T W rte, -�.tl�. <br /> in <br /> E FACILITY ADDRESS � <br /> SITE PHONE # with AREA CODE <br /> & X017 � <br /> CITY <br /> r I <br /> C A f STATE Z!P CODE # of TANKS <br /> P I 543 at SITE <br /> P APPLICANT/BILLING'iNAME <br /> L I it APPLICANT CONTACT NAME <br /> 1 .I <br /> C MAILING ADDRESS <br /> A APPLICANT PHONE # WITH AREA CODE <br /> N u d <br /> T Ci TY STATE ZIP CODE TYPE of APPLICATION ��(� <br /> (Closure, InstatLation, e c:7"" <br /> i� II TOTAL <br /> d <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) a $100.00 1986 1987 1988 1489 1940. <br /> A a <br /> C �I II S <br /> T FACILITY PENALTY FEES ASSESSED (!f Appticable) <br /> I XXXX XXXX 5 <br /> V TANK FEE = S50.00/tANKi (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = iI it 1986 1987 1988 1984 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply FW—fee; for,� <br /> A each year applicable) i S <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx S <br /> L � i <br /> I STATE SURCHARGE = I�$56!100 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> T # Tanks x 556!00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year)' <br /> h „ s <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) -0 <br /> L :1 <br /> 0 CLOSURE FEE - 578.i 000/hour (3 hours minimum/TANK) # TANK(s) <br /> S X $234.00 = pD6. g <br /> a <br /> U TEMPORARY CLOSURE {p(an�Review & Inspections) TANK I.D. #(s) <br /> R J. !� <br /> E TEMPORARY CLOSURE F,EE =;578.00/hour (3 hours minimum/TARK) # TANK(s) X 5234.00 = 5 <br /> Li <br /> PINSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L ., <br /> A <br /> N PLAN CHECK FEE a 578.00%hour (8 hours minimum/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 = 578.00/hour (3 hours minimum/TANK) # TANK(s) <br /> A X $234.00 5 <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour 0 hours min./FACILITY) = S234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE =� 578i00/hour (3 hours minimum/FACILITY) = $234.00 minimam ; <br /> �I <br /> M TRANSFER FEE : t20.00 UNAUTHORIZED RELEASE EVALUATION a 578.00/hr S <br /> I 3 <br /> 5 <br /> C CONSULTATION FEE = f78.00/hr SAMPLING INSPECTION FEE = 578.00/hr f <br /> I� TOTAL DUE S <br /> FOR OFFICE USE ONLY !� I <br /> _.........4Y^•'•.�'t:_s�i��„1^•:.Yy»a_�t�-.�._Y.«.t'tjyY��•L^S•••».. 't..__ <br /> -'..'..-....`._.�-1+....««�i�'...'r«..1'S...........r.i_.___.�.�4�FyL...�.:...-�.�_-�.-....:�»:..:...::«:«�...._:.h'r'�_—«.-F:.......r :�:...__.-..»..""..»:«'.::::t::::j-.^..i__:::i:::_S::.M:::�.�«���_:.^.«....:.•f.:i:s:i:��':•i��=�.x.._�•N._...:.:.^.».« "Y=»::: <br /> SWEEPS # Fa <br /> COMPUTER !!LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CAS}I�� RECEIVEi) BYDATE«RECEIVED <br /> 41 wan 3 a 5 Fa <br /> r-._•,....»....... ._......_;.»«;..�-• -•_-:.� .... _'m;:'-�� Ti�::� <br /> ra::.c:•::.c-'...��.a_ .. .....,..�.n:a—e:::a: ,»':::�i;H,i:>___—=•-�s_.. .�. •«.«... "�� -=�•::::::'-_— -- -- - i::t—•�n£'•r'-=_:r-r—s_-'"?�_'""-_s.��,�!;;a.�s <br /> —`==su:_._a-ue_a+,..«...... ...�:�.;...�_.._i.—..�ae�::•— <br /> EH 23 032 (REVISED 11-1-92), Page 11 <br /> 3 <br /> II �� <br /> �.. __.. h _.....,.. ... .................................. ......... .. =— -- <br />