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HEAL <br /> MENTAL <br /> SAN JoACUIN COUNTY pUNDIC HEALTHGE TSERVICE�S E1IYF�ONWORKSNEET TN DIY5ION <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAME Pf I/E e-1 <br /> I ',P.EEo STEl�. T <br /> Y <br /> SITE PHONE # with AREA CODE <br /> FACILITY ADDRESS; 7,1r � UAL�Co x'36 �- .. <br /> 5T TE ZIP CODE it of TANKS' 1 <br /> CITY 1 at SITE / <br /> r, Y <br /> APPLICANT CONTACT NAME <br /> APPLICANT/BILLING NAME <br /> L STG�/"�'� PPLICANT PHONE # WITH AREA CODE <br /> I , <br /> NAILING ADDRESS i �aG• $Z/� <br /> lvEtT �/A�'�/Co <br /> STATE ZIP CODE TYPE of APPLICATION �Psvirs�� <br /> T CITY (Closure, Installation, etc.) <br /> � T�fG <br /> TOTAL <br /> i <br /> - 1986 1987 � 1988 j 1989 1940 <br /> ` ANNUAL FACILITYIFEE (Prior to January 11 1991) = S100.Q0 XXXX xxxx XXXX XxXX XXXX S XxxxxxxX <br /> If Applicable) xxxx xxxx xxxx xxxx xxxx s XXXXXXXX I <br /> Y FACILITY PENALTY FEES ASSESSED { AP ', 1441) <br /> 1,1991) 5170/TANK (After January <br /> ! TANK FEE 550.00/TANK (Prior t4 January 1995 1996 11947 1998 <br /> how 1# Tanks = 1988 1989 1990 1991 1992 1993 1994 1 <br /> F (multiply # by fee for S <br /> xxxx xxxx xxxx XXXX' XXXX <br /> each year applicable) y I s <br /> l i <br /> rTANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXX% S - i <br /> I STATE SURCHARGEIFOR NEW FACILITIES ONLY=518.50 0 1993 through 1947 ($56) 1998 <br /> I 1988 through 1993 ($56) <br /> f # <br /> Tanks_ x $S.OD $ <br /> 1 XxxxxxxxxxxxxxXxxxXxXXX <br /> SURCHARGE FOR ;1998 xxXXXXXXxxxxxxx)o=xxxxxXxX ; <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) <br /> TANK I.D. *(s) <br /> L # TANK(S)--4- <br /> 10 <br /> ANK(S) X 5234.00 = 5Z 3' <br /> ,0 CLOSURE FEE = 'S78.00/hour (3 hours minimum/TANK) <br /> S TANK I.O. #(s) <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) S <br /> R <br /> E TEMPORARY CLOSURE FEE x $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction InspectionTTAAINJKD. #(S)LA .00 minimum <br /> N PLAN CHECK FEE,= S78.00/hour (8 hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) <br /> TANK I.D. #(s) <br /> -E X 5234.00 =: S <br /> P TANK LINING REPAIR FEE = 57$.00/hour (3 hours minimus/TANK) # TANK(s) S <br /> A = $234.00 minimal <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) 5 <br /> R a 5234.00 minimum <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br /> = s78.00/hr I s <br /> M TRANSFER FEE i' = 520.OQ UNAUTHORIZED RELEASE EVALUATION ' <br /> I � <br /> g = S78.00/hr <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE vp <br /> TOTAL DUE 5 Z3 <br /> USE ONL'T <br /> R OFFICE . :..._._ ;�- •• _ ...,,......_ _ _ <br /> .—.••»•»•..:–_•,•• _e:rs:-srssisseui�7iuE-:�:+r_cr�n:Cx::eoP•mv:: <br /> FOR RECEIVED., :. <br /> SWEEPS # COMPUTER # LOC CODE DIST LOGE AMOUNT RECEIVED CHECK #/CA5H RECEIVED <br /> ...__»..may„„..._ <br />