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SAN JOAOuIN COUNTY - IC HEALTH SERVICES - ENVIRONMENTAL HEALTH r--' �N <br /> UNDERG STORAGE TANK PROGRAM - FEE uOR]CMEET <br /> S FACILITY SITS NAMEI FACILITY CCNTACT NAME w <br /> I AR 4 <br /> T <br /> 'E FACILITY ADDRESS SITE ?HONE uith AREA CODE <br /> \1\\ <br /> CITY <br /> STATE ZIP CODE + of TANKS <br /> at SITE <br /> A �� I C)A 1l5��o <br /> P <br /> p APPLICANT/BILL <br /> ING NAME APPLICAALT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS^ ^ 1 APPLICANT ?HONE j WITH AREA CODE <br /> A <br /> N STATE ZIP CODE TYPS of APPLICATION <br /> T CITY 3} (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 I 1987 ' t988 11989 11990 <br /> ANNUAL FACILITY F=-- (Prior co January 1, 1991) = Si00.00 <br /> A XXXX I XXXX XXXX I XXXX I XXXX S XXXXXXXX <br /> C <br /> Tj FACILITY PENALTY FEES ASSESSO (If Applicable) XXXX ' XXXX XXXX I XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK r'c. = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January t, 1941) <br /> EI 4 tanks = 1988 11984 1 1990 1991 11992 11993 11994 ` 1995 ! 1996 11997 1998 , <br /> F (multipty by fee for <br /> AI each year applicable) ( XXXX XXXX I xxxx I XXXX XXXX I I ! ' S <br /> C <br /> II TANK PENALTY FEES ASSESSED XXXX XXXX XXXX ( XXXX XXXX S <br /> L <br /> II STATE SURCHARGE FOR NEL FACILITIES ONLY=SI8.50 5 <br /> T <br /> Y ' ranks x 58.00 I 1988 through 1993 CS56) 1993 chrough 1997 (356)1 1998 <br /> SURCHARGE FOR 1998 I xXXXXXXXXXXXXXXXXXXXXXXXXXX ' XXXXXXXXXXXXXXXXXMXXX S <br /> Ci ?ERMANENT CLOSURE (Removal or Authorized Closure-in-Placa) I TANK I.J. :(S) <br /> L, _ <br /> 01 CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) 7ANK(s) X 5734.00 - S <br /> S <br /> Ui TEMPORARY CLOSURE (Plan Review I Inspections) I TANK 1.0. ;t(s) <br /> R <br /> ETEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) f 5234.00 minimum S <br /> PI INSTALLATION ?LAN CHECK Celan Review 3 Constr^.=-.4on Inspections)I TANK I.O. +(s) <br /> L� <br /> A <br /> N ?LAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> i <br /> Rj REPAIR FcE (Workm an Review I Construction Inspections) I TANK I.O. T(S) <br /> C <br /> P TANK LINING REPAIR FEE = 378.00/hour (3 hours -ninimun/TANK) I 7ANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE- = 578.00/hour (3 hours min./FACILITY) = SZ34.00 minimum <br /> S <br /> R <br /> PIPING .REPAIR F.E = 578.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> MI TRANSFER FEE = S20.00 ! I 'JNAUTHCRIZJ RELEASE EVALUATION = S78.00/hr I I i S <br /> I� <br /> C; CONSULTATION F=E = S78.00/hr I I SAMPLING INSPECTION FEE = S78.00/hr <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> WE=-?S- S <br /> + COMPUTER S I LOC CE I GIST CODE AMOUNT RECEIVED I CHU <br /> ECK / Sii I RECEIVED3Y OATS ;EC:IVS — <br /> IS <br /> EH 23 332 (REVISED 1-12-98) <br />