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I LA <br /> SAN JOAQUIN IC HEALTH SERVICES - ENVIRONMENTAL I1qLr1r- 1a <br /> d <br /> STORAGE TANK PROGRAM - FEE ®a+6 9Sz O O <br /> S FACILITY SITE NAME FACILITY CON C E <br /> a _ <br /> /7 <br /> -T' <br /> °TI <br /> E FACILITY ADDRESS SITE PHONE # wrA ODE , J <br /> u � <br /> a <br /> CITY STATE ZIP CODE # <br /> A , ';'(I C.T Q� � Z C, at i <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> WIN— <br /> L - �L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> NE c C '�. <br /> T CITY STATE[!2E TYPE of APP <br /> e v oa 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 S <br /> I <br /> Y 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 $ <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 3 S Code, Section 25287 <br /> T <br /> Y N Tanks, x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> G PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(a) <br /> J� <br /> L J <br /> 0 CLOSURE FEE = S78.00/hour (3 hairs minimum/TANK) # TANK(s) X $234.00 = S ` <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hair (3 hairs minimum/TANK) # TANK(s) X $234.00 = f <br /> P tNSTALLATtON PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) i <br /> L <br /> A oG <br /> N PLAN CHECK FEE = S78.00/hoar (8 hours minimum/FACILITY) = S62¢.00 minimum $ (+.� <br /> R REPAIR FEE (Workp(an Review 8 Construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE _ $78.00/hoarp(3 hours minimum/FACILITY) 5234.00 minimum $ <br /> N TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr % <br /> 55 -f ?c 1 C�..V�?cr� C- <br /> 4 <br /> totA� <br /> � l n <br /> FOR OFFIt ONLY cru <br /> :,.. <br /> .•••.••.•?E?a r8?:�f?ii??i??f38443i3383 '. ° .. •».: BAifffff?ffR�?iffffffffi�.4?$$?4834 fH. :... REii?�?RffiffF°i':Hf.� �lif� ..rrx�?4'F?. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVE CHECK /CASH RECEIVED BY DATE RECEIVED P <br /> X88?838838338483sn^'i?:ii3�3:'.3i'?!i?fim£>£?41 .84 488888�f3"i:.nt18.83?i31ti1813 1i4883'd8ii1f884?li' ••• .., 8313• fil48it314E833f4i:33�tE848E8f !!fi8�3R!331.83?8{i,•g:es;??Pii381 <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />