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SAN JOACUIN COUNALIC HEALTH SERVICES . ENVIRONMENTAL VAT&ION <br /> UNDeIt=Q= STORAGE TANKWONKSHERT <br /> S FACILITY SITE NAME PAC LtTY CONTACT NAME <br /> I s ® �„ t <br /> T <br /> "E FACILITY AGO RESS SITE PHONE # with AREA CODE <br /> Cit STATE ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> P APPLt NT/BILLING NAME AP LICANT TACT NAME <br /> L i I A fO <br /> e X <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A •'"' >; <br /> N <br /> t CITY STATE Z10 CODE TYPE of APPLICATION dAV Scti'C— <br /> (Ctosure, Inatallation, etc.) <br /> TOTAL <br /> 1986 198? 088 1989 1940 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> XXXx xxxx mi xxxx ! XXXxxXXX <br /> A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) xxxx xxxx xxxx xxxx xxxx S xxxxxxxx <br /> I ,. <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) *170/TANK (After January 1, 1991) <br /> E <br /> 0 Tanks = 1988 1989 1990 1991 1992 1 1994 1995 1946 1997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx xxxx xxxx xxxx xxxx $ <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx xxxx xxv jxxxx $ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY-S18.50 $ <br /> T <br /> Y # Tanks x $8.00 1988 through 1993 (S56) 1993 the I"? .(156) 1998 <br /> SURCHARGE FOR 1998 XXXxxxxxxxxxXXXXxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx $ <br /> C PERMANENT CLOSURE (Removal or Authorized Ctasure-in-Pisce) TANK t.D. #(s) <br /> 0 CLOSURE FEE = 178.00/hour (3 hours mini TANK) 0 TANK(S)_,J_ x *236.00 = $ -7c) <br /> S <br /> U TEMPORARY CLOSURE (Plan Review $ inspections) TANK I.O. #(A) <br /> R <br /> E TEMPORARY CLOSURE FEE $ $78.00/hour (3 hours mini "W FACILITY) $234.00 minimum $ <br /> P INSTALLATION PLAN CHECK (Plan Review $ Constructs Inspections) TANK I.D. #(§) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours mini FACILITY) *626.00 minimum <br /> R REPAIR FEE (Workplan Review $ Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) x 1234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE 2 578.00/hour (3 hours min./FACtLITY) $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours mini FACILITY) a $234.00 minimum $ <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION a 578.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SA14PLING INSPECTION FEE : S78.00/hr <br /> TOTAL DUE <br /> Q y <br /> FOR OFFICE USE ONLY <br /> -� <br /> EPS # COMPUTER # LOC CODE DIST CODE t RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> a w <br /> M <br /> !t6•*tEECt!4m4As(pps??imft?� .Elr�-i,.,fid, :. ",3�,Feo•£. ..._•• .e•-rr ••..r,:.n:f <br /> :gsuia?fe 3 sifN?ii�":ii£1fi68 "+�£Ls?{ii£F.S�.:�r^.asz 3 E&kl <br /> cu n?.7 (RFVISFO 1-12-98) <br />