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SAN JOAQUINIC HEALTH VICES - I AL DIVSION <br /> ST T - FEE <br /> SFACILITY SITE NAME ® FACILITY CONTACT NAME <br /> ®T I <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & e <br /> CITY TA IP CODE # of YANKS <br /> A at SITE <br /> P 4� � C` <br /> P APPLI NT/BIL NG N7 APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CI, AT ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A XXXX XXXX $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX $ <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # 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 $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX $ <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 19% <br /> (Enter amount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 - $ sj <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours mini TANK) # TANK(s) X $234.00 = $ <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) 1-7 le 5 <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hoar (8 hours minimum/FACILITY) _ $624.00 minimum $117)QL <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK S.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hoar (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> ::•.r.:::::�e::a:::::tt.„r.:1F?d=dTdddldd?£??!::'.143i9@Sdiidi?5-:...» ..:.•�•.».»..........». »»». ....»...»...» »..P.::=c...„^..».. _..... •..... ::?Bi?iL�diLr-:z•a"ux»»—.i»<i!d?zd= <br /> _.._.._...»....»......... .....p»...» »» <br /> _»._...»».•iiRd?:ci id:sieiiiid333ddi£dd£idai•�i:m"FFA$dddd'a„4i:'•'•'s_..z•"'ddi7edid"riiir'•�'...•»••»•••••••••••» »•�s' i0iddid":eeEsd�'�i•"...F.'G'»4.?. :4'ddd£dddtddds:..°«?�EBi�fidA?!si:« °•il?dddd „:i:.=„diciiix•...•'• r.•s"'0idz.sT...'•�.io:..•••.'•^:.�.c=:.'�..�id d^r::di#�•..: <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE NT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> "•`:•:.m».:a d»»..•s.»•.'mss "..».•»..:•.:...» .;erMzu:,:„e:S"rd:dd?d=»==.E:„^». ,u�....»..._» <br /> $ <br /> »........... .. ••":: �.Wim»_ ..-......... »»....»».».....»». ...»»»»»»»..:».. <br /> Mrs::ciii�:dE.^.ie”s:""»�iuudcaw:ua� :sddddFdi.��'.iiiddP.�fdF.ddildiiir'»•» .• ».'�.. d'•.dF.xa zidoieidi£:d':=s:id£dddf6'�d'sddSd°°»�:�ddd?dad"s.�!'u'L�:fddE.4ddF.atsuddlld"sdididdiid`��i,,�•�.,•i'. .. tta: dididd <br /> EH 23 032 (REVISED 6-21-93) Page 11 V �' <br />