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SAN JOAQUIN C PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION //��1111 } qq T97 <br />UND RGROUNO STORAGE TANK PROGRAM - FEE unmxsNFFT /'I C 1 /-' <br />S <br />FACILITY, SITE NAME <br />13 <br />FACILITY CONTACT AME q(, <br />7 �5 <br />r <br />i) <br />I�f'1-;` c.cLl.t jN fZS <br />E <br />FACILITY ADDRESS /.lSITE <br />PHONE # with AREA CODE <br />F <br />CITY 7 <br />'/1 �'�tt'I <br />/1,TR,AlTE <br />ZIP CODE <br />('J�(„ <br /># of TANKS <br />at SITE <br />Xxxx <br />1111 <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />LcL <br />iE.:.11�lL� <br />7 GA�'� <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />F <br />A <br />C <br />T <br />CITY I <br />� <br />STATE <br />ZIP CODE <br />"� <br />TYPE of APPLICATION <br />1990 <br />1991 <br />j <br />� - <br />RClosure) Installation, ate.) <br />i) ALO tnTAI <br />A <br />C <br />ANNUAL FACILITY FEE (Prior to January i, 1991) = $100.00 <br />1986 <br />1987 <br />11988TI989 <br />1990 <br />$ <br />T <br />I <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />Xxxx <br />XXXX <br />S <br />V <br />E <br />TANK FEE = 550.00/TANK (Prior to January 1,1991) <br />5170/TANK <br />(After <br />January <br />1, 1991) <br />F <br />A <br />C <br /># Tanks <br />(multiply # by fee for <br />each year applicable) <br />1986 <br />1987-11988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />5 <br />1 <br />L <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XKXX <br />5 <br />1 <br />T <br />STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H 6 S Code, <br />Section 25287 <br />Y <br /># Tanks x $56.00 <br />(Enter amount and year) <br />1986 through 1990 <br />1991 through 1996 <br />S <br />C <br />L <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(a) <br />0 <br />S <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s)_Z X <br />$234.00 <br />U <br />R <br />TEMPORARY CLOSURE (Plan Review 5 Inspections) <br />TANK I.D. #(s) <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum <br />f <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) <br />TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE = 578.00/hour (8 hours minimu VFACILITY) <br />= $624.00 minimum <br />$ <br />R <br />E <br />REPAIR FEE (Workplan Review 8 Construction Inspections) <br />TANK I.D. #(a) <br />P <br />A <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) <br /># TANK(s) X <br />5234.00 = <br />S <br />I <br />R <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum <br />S <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimun/FACILITY) <br />= $234.00 minimum <br />5 <br />M TRANSFER FEE = $20.00 <br />S <br />L ICORSULTATION FEE = S78.00/hr <br />FOR OFFICE USE ONLY <br />r- ---€H 73 032 (REVISED 3-1-93) • <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />SAMPLING INSPECTION FEE <br />= 278.00/hr <br />S <br />5 <br />TOTAL DUE 15 <br />Paae 11 <br />/ I <br />