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SAN JOAUUIN T PUBLIC HEALTH SERVICES - ENVIRONMENTAL <br /> DIVSION <br /> MW <br /> GROUND STORAGE TANK PROGRAM - FEE WORKSH <br /> ILITY SITE NAME FACILITY CONTACT NAME <br /> I-AKWMO Gtr%V01V &45;4/ P4-16f- <br /> E FACILITY ADDRESS / G,�hv SITE PHONE # with AREA CODE <br /> Al PAM <br /> L l0 <br /> CITY � ` STATE ZIP CODE # of TANKS <br /> A (�p�� 4 5�0 at SITE ' <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> G 11 C• Gn a a cs /qc <br /> C MAILING ADDRESS / APPLICANT PHONE # WITH AREA CODE <br /> NC. /t✓ — 1 <br /> T CITY , STATE ZIP CODE TYPE of APPLICATION /u�S�I�� BIU <br /> L ` 2Y(7 (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990' <br /> A XXXX XXXX XXXX XXXX S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX 5 <br /> I <br /> E V TANK FEE = 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> # Tanks1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # y fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX <br /> C $ <br /> t�' <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX g <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 $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal ofthorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/h (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE an Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY Cl RE FEE = $78.00/hour (3 hours minimun/FACILITY) $234.00 minim $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minim $ <br /> R REPAIR FEE (Workp(an Review & onstruction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FE 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFITR IR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> R <br /> PIPING REP R FEE = $78.00/hour (3 hours minim/FACILITY) = 5234.00 miniimun $ <br /> N TRANSFER FEE _ $2 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATIO EE _ $78.00/hr SAMPLING INSPECTION FEE = 578.00/hr 5 <br /> TOTAL DUE 5 �3pa�00 <br /> FOR OFFICE USE ONLY <br /> ...:....._._._. ............._........._..._..._._... ...».».._..«...rx::aW:r.:ne-« •r..E .^.^.—ar...--'^---..»........�. _...�.._. .».. <br /> .::.............. .......................... ...._..—........_ _...._ ......................__..:»s.f?:_._.i.......... ........_ .»............._._..._......_,..r...r._............e....r. e..__....... ....sxn:�.;;__««...;« <br /> u:: :::::I._uuW W W Wr:::ttus:at_ts..._.. ...»t......t..... ....................................::�:::r.:�::::r:::� ::::::_::::�::.^. <br /> •••• i..iYWGLW.1JCYtCE:•••••••••••—•••••:iy:it�,:::::•••:-_••••»••••• t:isi::::::«I:WStYL•t:Y�.::::istW:W4UiYn•••••••••••••••»•»••Si:ittiY:LJ.:::W:ll::L••:i:ti:J•1:151i':S:iWW:WW:::i <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED s <br /> r: <br /> Sc7 <br /> 3 <br /> eiiiu.i... <br /> ............. ....3 <br /> .......••.•.._».�:::w:•........•...u:::•::s:::;sue::::�:,_..:c..+_ua�nuu:t:a::::::aiW::u:Wcuui:sss�ff..o.-:_,:;;_;:,::::r.•q;s�.=:..»:z:,.:..:::.i::z..e:_•s::W::a�:�::::s:a:.uii:u:uc'_iuueiAliiii�;:::a:::c::::r•:::::iiiiiiE:ii <br /> . .s....:s_...:i..iuuu <br /> A <br />