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SAN XAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OIVISICN <br /> UNDERGROUND STORAGE TANK PROGRAM - F»c»c 4CRXSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A <br /> C <br /> I FACILIi ADORE" , SITE PHONE X with AREA CODE <br /> L • <br /> I <br /> T CITYSTATE ZI CODE X of TANKS -7) <br /> Y S 5 at SITE <br /> A APPLICANT/BILLING NAME AP LICANT CONTACT HARE <br /> P 'aS C <br /> L Joe <br /> I MAILI G ADDRESS AP CANT PHONE X WITH AREA CODE <br /> C <br /> A q <br /> N CITYsin TAi ZIP S TYPE of APPLIUTION F�QGK S� �n <br /> i CLOSURE, INSTALLATION, etc. <br /> A !CSU a �) •9Z - ��- / S'. cyJ-•_�. TOTAL <br /> C 1986 1 87 1 1988 1 1989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 7 <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) 2170/TARK (after January 1, 1991) <br /> F X Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (muttipty X by fee for � � <br /> C each year applicable) 1150-11� 39ACl L��' o00 I I cqD I I I I 5 1 <br /> I <br /> L STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T X Tanks z 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 5 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. X(s) _,2 f& Z — ffd o3 <br /> C <br /> L CLOSURE F"t'c - 553.00 per hour (3 hours minimum per TANK) X TANK(s)= X $159.00 S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. X(s) <br /> R <br /> E TE14PCRARY CLOSURE FEE - 5150.00 each TANK X TANK(s) X $150.00 = S <br /> P PUN CHECK (Install. Ptan Review & Construction Inspections) TANK I.D. X(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minimm per Facility) = $424.00 minimum S <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. X(s) <br /> E <br /> P TANK REPAIR FEE = 553.00 per hour (3 hours minimum/TANK) X TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = 553.00 per hour (3 hour minimum per facility = 5159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = S 53.00/hr Ail I 2r <br /> y 77 t y ;7_7,c33� = a9a TOTAL DUE S 310 <br /> OFFICE USE ONLY a p <br /> sis -TS'r's vrs.�s ,s assns: <br /> i'°c v r'T I '�J'�°ii c 2M <br /> i I <br /> ._.... <br /> ...... <br /> _.__ _.................._»...._ »__....... rites ..........._....�..__»..._._..3 <br /> ii{]�:Y��{tlfi�/iilNil�lA�O],rJ�f{>t�l tA{iflilY�]1�iYi�lOr.�l=/�Rli Yf!{Y,ai.�fa 11�>•{Ai11YIfilAili�1>•i1•�1r.1 <br /> \V <br /> EN 23 032 (REY 1/10/911 ft Pace 11 ..� JG1 <br />