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SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL HQft DIVSION <br /> ROUND STORAGE TANK PROGRAM - FEE YORKSH <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I -er L[ <br /> T 4-0 <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & 3 9L,0 f 909 ^ 7- 900 <br /> CITY TATEI ZIP CODE # of TANKS <br /> A &Lill (+S'�.® at SITE <br /> P <br /> P APPLICANT BILLING NAME <br /> APPLICANT CONTACT E <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> NI 15- I ® - ^ 6 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> S.Z ® (Closure, Installation, etc.) <br /> TOTAL <br /> 1 , 1 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 1986 1987 1988 1989 1990 <br /> A XXXX I XXXX I XXXX XXXX XXXX $ XXXXXXXX <br /> C <br /> Ii FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX XXXX I XXXX I XXXX i XXXX $ XXXXXXXX <br /> V) TANK FEE _ $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1987 11988 1989 11990 1 1991 ! 1992 , 1993 11994 1995 11996 1997 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX ( i I $ <br /> C <br /> 11 TANK PENALTY FEES ASSESSED I XXXX I XXXX I XXXX I XXXX XXXX <br /> L' <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 ,5 <br /> T <br /> Y # Tanks x $8.00 I 1988 through 1990 ($56) 1991 through 1996 (S56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ <br /> L' PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) I <br /> OI CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> NL PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P1 TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R 00 <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 I UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I $ <br /> I <br /> S <br /> C, CONSULTATION FEE _ $78.00/hr I SAMPLING INSPECTION FEE = $78.00/hr I I $ <br /> TOTAL DUE $ d O <br /> FOR OFFICE USE ONLY <br /> _ _ <br /> •�_ M:::: ::ss:::::: ::a s:aw:::aa::_:-:aaa_::: _ :: :«=:—T='"_' _== :si H€'ss€€ w €€ w€u_ '€s= —�.—:;.^T_==_:-:::-:=--=at ate........................... <br /> ::s:si: t::= <br /> _ ___... _..-..._..-_.-..................__........................ <br /> _.. _. - _ <br /> SWEEPS # I COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED 1 CHECK #/CASH RECEIVED BY ( _ DATE RECEIVED- <br /> ----------------- <br /> EH 23 032 (REVISED 5-27-97) <br />