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SAN JOAQUIX COUNTY KMIC gMTH SERVICES . ENVI AL REALTH D MION <br />L=eRG=X0 STORAGE TANK - FEE NORlmeI T <br />- <br />FACILITY cb:mTACT NAME <br />® FACILITY SITE NAME <br />MOO( X7= <br />A <br />I <br />SITEPHONE; # with AREA CODE <br />FACILITY ADDRESS <br />—VX V—e C— /CL -6A <br />5170/TANK (After January 1, 1941) <br />E 1986 1987 1988 t989 1940 <br />STATff <br />ZIP CSE# of TANKS <br />CITY <br />F (rtuttipty $ by fee for <br />O :t SITE 3 <br />A <br />p <br />APPLICANTICONTACT NAME <br />p;APpLICANT/8ILLING NAME <br />S <br />L' 81.1 I N rJL'1 <br />�t+M �zu A -t <br />t <br />APPLICANTIPHONE S KITH AREA CODE <br />C MAILING ADDRESS <br />ClPERMANENT CLOSURE (R�wva( or Authorised Ctosure-in-Place) <br />K <br />STATE ZIP CODE TY E of APP <br />T CITY <br />(CLosure, nstattation etc.) <br />.FOR OFFICE USE ONLT <br />a WEEPS CCMPUTER -" I LOC CODE I DIST CCOE AMOUNT RECEIVED I CHECK <br />S <br />EH 23 032 (REVISED 10-28-93) <br />CT?q <br />RECEIVED <br />RECEIVED BY i DATE RECEIVED <br />I <br />, r"r,- I G 1 7, <br />1986 1987 1988 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br />$ <br />MOO( X7= <br />A <br />C <br />T FACILITY PENALTY FUS.A558SSE0 (If Appticabte) <br />XXXX XX70C $ <br />i <br />V TANK FEE = S50.00/TANK (Prior to Jansat�r 1.1941) <br />5170/TANK (After January 1, 1941) <br />E 1986 1987 1988 t989 1940 <br />9991 19927 '1993 1994 1995 1996 <br />II Tanks = <br />F (rtuttipty $ by fee for <br />S <br />A: each year applicable)• XXXX X)00( <br />C <br />L TANK PENALTY FEES ASSZ: D XXXX XXXX <br />S <br />L <br />I' STATE SURCaARGE = S56.40 each TANK (Dut every 5 years) See Catifarnis N & S�Code, Section 25287 <br />T 1988 through 1990 <br />Y II Tanks x 556.OD <br />1991 through 1946 <br />Es <br />(Enter amount and year) <br />ClPERMANENT CLOSURE (R�wva( or Authorised Ctosure-in-Place) <br />TANK I.D. #(3) <br />l <br />0 CLOSURE FEE = 578.00/hour C3 hours IOintaua/TANK) <br /># TANk (s ):--._' �. X $234.00 = 5 <br />STANK <br />(Plan Review & Inspections) <br />I.D. 9(s)0 <br />TEMPORARY CLOSURE <br />RS <br />CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minij= <br />E TEMPORARY <br />CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #('s) <br />P INSTALLATION PLAN <br />L <br />A <br />PLLECK fiE = 578.00/hour (8 hours miniauA/FAGILITY) <br />= $624.00 miniaxm S <br />N <br />Review & Construction Impections) <br />TANK I.D. 90s) <br />R REPAlR FEE (Workplan <br />E. <br />P TANK LINING REPAIR FEE n S78.00/hour (3 hours miniminITANK) <br />9 TANK(s) X 5734.09 <br />A <br />FEE = S78.00/hour (3 hours min./FACILITY) <br />= $234.00 minimus S <br />I' TANK RETROFIT REPAIR <br />R$234.00 <br />i PIPING REPAIR FEEa 578.00/hour (3 hours :inim �/fACILITY) <br />- -minimum = <br />MTRANSFER FEE Ig S20.00 UNAUrrMIZED RELEASE EVALUATION = $78.004hr <br />s <br />i <br />5= <br />C <br />CONSULTATION FEE = $78.00/hr SAMPLING IHSPEC7fON FEE <br />S78.00/hr <br />S <br />TOTAL DUE <br />S <br />.FOR OFFICE USE ONLT <br />a WEEPS CCMPUTER -" I LOC CODE I DIST CCOE AMOUNT RECEIVED I CHECK <br />S <br />EH 23 032 (REVISED 10-28-93) <br />CT?q <br />RECEIVED <br />RECEIVED BY i DATE RECEIVED <br />I <br />, r"r,- I G 1 7, <br />