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SAN JOAQIIN COUNTY PUBLIC HEALTH SERVICES - ENVIRMWffAL HEALTH DIVISION <br /> UNDEROedDNI STORAGE TANK PROGRAM • FEE WORT <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I tar 17•�t7tti, S bv� O I7,3 IVA <br /> E FACILITY ADDRESS SITE <br /> -FPHONE # With AREA CODE <br /> a 103 Ce riNA <br /> CITYC STATE ZIP CODE # of TANKS <br /> / <br /> P <br /> P APPLICIA'NT/BILLS G NAME APPLICANT C/nO�NTACT MANE <br /> L V(local CC n r n /tfn. sf'D n <br /> C MAILING ADDRESS / APPLICANT PHON�E1# WITH AREA CODE <br /> w a000 L..) Cc� o . o� - T�-!� Oa <br /> T CITY STATE ZIP CODETY PPLICATION <br /> 5 GLn1 p� 3 C louvre Instal Latton, etc.) <br /> TOTAL <br /> 19r 1 <br /> ANNUAL FACILIT7 FEE (Prior to January 1, 1991) = 5100.00 86 1987 1988 1989 1990 <br /> A XKxx xxxx XXXX xxxx xxxx S XMIcaccono X <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX xxxx I X)= xxxx xxxx $ xxxxx)00(XXxxx <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 2170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks �- 1986 1987 1988 1989 1 1990 1991 11992 1993 1994 1995 19% <br /> F (multiply # by Fee for <br /> A each year appsiDabte) xxxx xxxx xxxx xxxx <br /> c <br /> I TANK PENALTY FEES ASSESSED X)= xxxx xxxx X=L l XXXX ,� 11'j-t '].n i'L. 1'� S Q L U <br /> It 1U <br /> 1 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H L S Code, Section 25287 <br /> T <br /> Y # Tanks x S56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year; <br /> S <br /> Ci PERMANENT CLOSURE (Ramaval or Authorized Clasure-in-Place) 1 TANK I.D. d(s) — <br /> L `lf <br /> Z <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) ! # TANK(S) X 5234.00 • S Z J� <br /> S <br /> U TEMPORARY CLOSURE (Pian Review i Inspections) I TANK 1.0. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimWFACILITY) 5234.00 minimuA 5 <br /> PI INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PUN CHECK FEE = S78.00/hour (8 hours miniaAm/FACILITY) = $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review L Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE - S78.00/hour (3 hours minimum/TANK) ' # TANK(s) X 5234.00 = 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 S78.00/hour C3 hours mininmm/FACILITY) = S234.00 mini mu, S <br /> M TRANSFER FEE S20_COI UNAUTN13RIZEO RELEASE EVALUATION = S78.00/hr I S <br /> S I I <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE - S78. /hr S C�)) <br /> TOTAL DUE S M 3 C16 <br /> FOR OFFICE USE CULT <br /> SWEEPS d COMPUTER # i LOC CODE DIST CODE I AMOUNT RECEIVED i CHECK #/CASH I RECEIVED BY I DATE RECEIVED <br /> .-_—.__.__-1_ <br /> — <br /> -- <br /> £ d � QL -�� —HJ02i.� WdLZ Z 9661-91-Z l <br />