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SAN JOAOUINA&M PUBLIC HEALTH SERVICES - ENVIRONMENTALTH DIVSION <br /> RGROUND STORAGE TANK PROGRAM - FEE YORKSH <br /> atro � 1 <br /> TI FACILITY SITE NAME I F T CONTAC, AME <br /> Ei FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> LJ �° .5 <br /> CITYT TES ZIP CODE # of TANKS a <br /> AI at SITE <br /> P <br /> LIAPPLICANT/BILLING NAM ® APPLI CONT T NAM p <br /> C; MAILING ADDRESS c I APPLICANT PHONE # WITH AREA CODE <br /> Al ® C �c !�� <br /> N <br /> TI CITY <br /> STATE! P,.ZODE TYPE of APPLICATION <br /> i (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 i 1988 1989 ( 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A! xxxx I xxxx xxxx j xxxx I xxxx S xxxxxxxx ;I <br /> I Cii <br /> TFACILITY PENALTY FEES ASSESSED (If Applicable) ! XXXX i XXXX i XXXX XXXXXXXX S XXXXXXXX <br /> t I <br /> V' TANK FEE = S50.00/TANK (Prior to January 1,1991) i S170/TANK (After January 1, 1991) <br /> E <br /> Tanks = 1987 1988 1 1989 1990 ; 1991 1 1992 1993 11994 1995 i 1996 j 1997 <br /> C -r (muitioly # oy fee for <br /> 4 A; each year acoticable) XXXX XXXX XXXX XXXX jXXXX i S <br /> g C <br /> F <br /> o I': iANK PENALTY FEES ASSESSED I XXXX XXXX XXXX I XXXX XXXX i j i 5 <br /> c L <br /> jr Ii STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 5 <br /> T' <br /> Y' # Tanks x S8.00 1988 through 1990 (S56) 1991 through 1996 (S56)1 1997 1 y <br /> V <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXxxxxxxxXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Ciosure-in-Place) I TANK 1.0. #(s) <br /> L <br /> 01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> S <br /> UI TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. #(s) <br /> R' tl <br /> a <br /> Ei TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I $234.00 minimum S <br /> P'; INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br /> L, <br /> Aj <br /> NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> i <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E; <br /> PI TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s) X 5234.00 = S <br /> Alp <br /> II TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum $ ! 5i <br /> R' <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum S < <br /> N) TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I S <br /> I, <br /> CI CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE 5 t. <br /> FOR OFFICE USE ONLY <br /> ::•:_.::_. :::::::::::¢;a:::a:-as::_z :s::::s:::s:::s: mss¢ w€ . _ — <br /> SWEEPS # I COMPUTER # I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/CASH I RECEIVED 3Y I DATE RECEIVED <br /> EH 23 032 (REVISED 5-27-97) <br />