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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - EIVIRCNMENTAL HGLtn Ut"IUM <br /> 'WERGROUNO STORAGE TANK PROGRAM - FE: WORKSHF— <br /> •+ S FAC LITY �S(TE NAME FACILt` f CMVACT NAME <br /> - ! <br /> T <br /> - 'E FACILITY ADORES SITE PHONE X with AREA CODE <br /> & 3.3 �, ,<k Si , (Wq) 1'15-7,(7-( <br /> CITY • ST TE ZIP CODE I x of TANKS <br /> A r�1 �/� CiS7Y�,b at SITE <br /> P (� <br /> P APPLICANT/BILLING NAME APPLLCAA T CDN A I NAME <br /> I <br /> C 14AILING ADDRESS APPLICANT PHONE 9 WITH AREA C13DE <br /> N <br /> T CITY dYI V SJA E ZIP CODE I TYPE of APPLICATION <br /> CAI ej,%, S 1 I (Cl.wure, Installacion, etc.) <br /> TOTAL <br /> 1986 11987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> AXXx( I XXXX I xxa I )0= I xxxx s xxxxx%XX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED Cif Applicable) I xxxx I xxxx I x00( XXXX xxxx S XXXXXX%X <br /> I <br /> VI TANK FEE = SSO.00/TANK (Prior to January 1,1991) I 5170/TANK (After January 1, 1991) <br /> E <br /> x Tanks = 11988 1989 11990 11991 11992 11993 1994 11995 11996 1997 11998 <br /> F (multiply by fee for <br /> A each year applicable) x%XX xxxx I XXXX xxxx IX%XX I I I I S <br /> I <br /> ( TANK PENALTY FEES ASSESSED I XXXX I XXXX I I I XXXX XXXX I%XXX I I 5 <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY-518.50 5 <br /> T <br /> Y X Tanks_ x 58.00 1988 through 1993 (S56) 1993 through 1997 (556) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXX%XXXX%XX%XXXX XXXxxxxxxxxxxXXXxxxxxxx I 5 <br /> Ci PERMANENT CLOSURE (Removal or Authorized C(asure-in-Place) I TANK I.O. :(5) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I Al TANK(S)—It, X 5734.00 S �� <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK LD. .'.(s) <br /> R <br /> E': TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimuR/FACILITY) I 5234.00 minimum <br /> 5 <br /> P INSTALLATt DN PLAN CHErCX (Plan Review & Construction Inspections) TANK LD. '+(s) <br /> L <br /> A6� <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.O. %(s) <br /> E <br /> P TANK LINING REPAIR FEE - 578.00/hour (3 hours minimum/TANK) I x TANK(s) X 5234.00 = 5 <br /> A = 1734.00 minimumS <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br /> R 5 <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 mini mum m <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION - 578.00/hr I I S <br /> I <br /> S S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE - 578.00/hr <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY _ _ _......... <br /> -- �SWEEPS 3 COMPUTER LOC C.DE OIST CODE AMOUNT REL'E IVED CSECK 3/CASH I REC_2 JED 3T I DATE RECEIVED <br /> bm <br /> EH 23 032 (REVISED 1-12-981 <br />