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GROUND STORAGE TANK PR FEE YORKSNE __ <br /> SAN JOAQUIN TY PUBLIC HEALTH SERVICES - ENVIRONNENTA LTN DIVISION .* <br /> S FACILITY SIT NAME FACILITY CONTACT NAME <br /> I > �✓ /e <br /> Ir— <br /> T <br /> E FACILITY ADDRES SITE PHONE # with AREA CODE <br /> "W// <br /> & <br /> CITY STATE ZIP CODE # of TANKS <br /> A .71119533-7 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L 0/ / <br /> IrV <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A / ( lot - 0// <br /> T CITY STATE ZIP CODE TYPE of APPLICATION t <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX S� <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX E <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 mini A ` S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 mini A'§Afcr S <br /> N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00 '- 0 H EALTH SERVICES 5 <br /> TOTAL DUE E <br /> r <br /> FOR OFFICE USE ONLY <br /> mmm2£lmiiMm??££!!?fS2??MHI????iH?IF?£wL'?£!£?'?.a.'!in.q*..Mq nim£?£rc.:...:n...r.:£n.r.o.??£?££ftm£IP!?-?R?I?m!£.m—fIT:!£I?I£??IF!ir:milnm?sMm.�R£?m mall???rs£S??£R'..!r".Fi T:i£?£!m££?n?£l?!m£:::?!??Mr:4iE??r:.'I£?£I"??m??:I££?£?m£?Sin?i£i?h2Sl"£?mrd?I££Gi3!?£i:•:iP.m??£?R1m£m£ii!I?£?£:?N£R?£R!! .. <br /> ""?r�E£I?i£fr£m?f£i??i?££iHiiE?£L ii££t£dn£H£?it£I?S?E£E38£n£mim£m£[£i'r'£i m i££££?££n??ni£M£I££inm£rx?m££i£if?£? <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> £n::iii£?ni££?£?££!n:�::iu"::£n:":n?n££?£n!infF?£I?!I!n!nni::.?i££i£$£!in?!ftitrsnen?n£?n£i?i£i£fi?nn£ii:s <br /> n£nn fII£I?.N£:£n??£????i?£££££????£?££?iin£:??£££?£££££i?i?£n?fi£i£i£mn%££iF£? <br />