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SAN JGAOUIN COUNTY PUBLIC HEALTH SERVICES . ENViMENTA EHEALiH DIVSION <br /> (pAR)-'RGRCLSTORAGE TANK PROGRAM - <br /> `i ti�------ NAME <br /> FACIL' Y SITE NAME a� ,/ i� �� <br /> I I AC'L:TY CrN'.fY <br /> T <br /> .EI FACILITY ADDRESS �y I SiiE P40NE 4i:h AREA CODE <br /> ()X--192p) ST/�iC 7a -IoSS <br /> Cl '/^ STA 'c ZIP 21 a4 TANKS <br /> A <br /> '(J at SITE <br /> p I APP L! NT CONTAM A <br /> P APPLICA /SILLIN ME 0 <br /> L d 2Xc+IUATI�6 / r7aL/ <br /> I I APPLICANT ?40 E ' WITH AREA CODE, <br /> wMAILING ADDRESS .v "0?/L) L::7 <br /> �S11�AZIP CODE PLICATION <br /> T <br /> asur Installation, etc.) <br /> TOTAL <br /> 1986 i 1987 1988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 XXXX XXXX XXXX *= XXXX '.5 XXXXXXXX <br /> A <br /> CXXXX XXXX xXXX I XXXX I XXXX S XXXXXXXX <br /> TI FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> t 1 <br /> Y TANK FE_ = 550.00/TANK (Prior to January 1,1991) II 5770/TANX (After January 1991) 1 <br /> E' <br /> 3 Tanks = 1988 1989 11990 j 1991 1992 1993 1994 11995 1996 11997 1998 i <br /> F (muLn oly : by fee for j <br /> A each year appLicac(e) I XXXX I XXXX I XXXX %XXX �XXXX 5 I I { <br /> C <br /> ( TANK PENALTY FEES ASSESSED I XXXX %XXX I %XXX XXXX ;XXXX S <br /> L 5 <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=S18.50 <br /> T <br /> T : Tanks_ x 58.00 1988 :hrcusn 1993 (S56) I 1993 :hrougn 1997 (S56) T998 ' <br /> "URCHARG' FOR 1998 I XXXXXXX%XXXXXXXXXXXXXXXXXXX ' %XXXXXXXXXXXXXXXXXXXXXX j S <br /> Cj PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK [.D. =(S) <br /> L' <br /> OI CLOSURE FEE = 578.00/hour (3 hours miniaaaa/TANK) TANK(s)� % $ 4.00 <br /> Sr <br /> Ul TEMPORARY CLOSURE (?Jan Review 3 InSpectiare) I TANK I.D. :(5) <br /> R ! S <br /> E TEMPORARY CLOSURE =EE = 578.00/hour (3 hours minimm/FACI L:TY) II SZ34.00 minimum <br /> PI struction Insoec:ians)i TANK I.D. :(s) <br /> L <br /> A S <br /> N ?LAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5624.00 minincnP <br /> Rl REPAIR --= (VarkoLan Review 3 Construction trspeC-ions) iANK (.O. #(s) ' <br /> E <br /> p� TANK lINIHG REPAIR FEE = 578.00/hour (3 hours minimus/TANK) TANK(s) X 5234.00 = S <br /> A S <br /> Il TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = SZ34.00 minimum <br /> R <br /> ?[PING REPAIR FEc = 578.00/hour (3 hours mininxm/FACILITY) = 5254.00 mininam 5 <br /> Ni TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> ItI I <br /> S' <br /> CI CONSULTATION FEE = 378.00/hr SAMPLING INSPECTION FEE = 578-00/hr 15 <br /> TOTAL DUE i 5 <br /> N OFFICE USE ONLY _-- <br /> .--__—.—=rte—� <br /> SWEEPS : COMPUTER Z- LOC CODE it OIST CODE AMCUNT RECEIVED II CHECK -l/CASH RECEIVED BY DATE RELIVED _ <br /> EH 23 032 (REVISES) 1-12-98) <br />