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SAN JCooU," AMIC HEALTH SERVICES - ENVIRONMENTAL H N DIVstem <br /> SIORAOE TANK PRMPAW- FEE WCRKSHEE�A 11 <br /> FACILITY SITE NAME I FACILITY CONTACT HA:.E <br /> I Triple E.Produce Tom Guido <br /> T SITE PHONE f with AREA CODE <br /> E FACILITY ADDRESS <br /> 8690 Urine Rd. (209)835-5123 <br /> $ CITY STATE ZIP CODE at SITE NKS 2 <br /> A Tracy CA 53 8 <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME Same a5 above <br /> L Same as above <br /> I APPLICANT PHONE R WITH AREA CODE <br /> C MAILING ADDRESS <br /> A PO Rx 239 <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY Tracy, CA 95378-023 (Closure, Installation, otc.) Removal <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • $100.00 $ <br /> A <br /> [ xxxx xxxx 1 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I $170/TANK (After January 1, 1991) <br /> V TANK FEE • $50.00/TANK (Prior to January 1,1991) <br /> E <br /> f Tenk! • 1986 1987 1988 1989 1990 1991 1992 1995 1994 1995 1996 <br /> F (anitlPlY I by fee for f <br /> A each year applicable) <br /> C $ <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx <br /> L <br /> I STATE SURCHARGE • $56.00 each TANK (Due avert' 5 years) See California NRS Code, Section 2528 <br /> T 1991 through 1996 <br /> Y a Tanks x t56.00 1986 through 1990 <br /> (Enter amount and year) f <br /> C PERMANENT CLOSURE (Remove! or Authorized Ctosure-In-Ptace) TANK I.D. 1(t) <br /> L TANK(s) X $234.00 • 1 468.00 <br /> 0 CLOSURE FEE • $78.00/hour (3 hours minim m/TANK) - �- <br /> S TANK I.O. f(s) <br /> U TEMPORARY CLOSURE (Pion Review $ InsPecti Ona) <br /> R $ <br /> E TEMPORARY CLOSURE FEE • $78.00/hour (3 hours m(nlsuAm/TANK) 1 TANK(s) X 1236.00 <br /> P INSTALLATION PLAN CHECK (Pion Review 1 Construction Inspections) TANK I.O. f(a) <br /> L <br /> A • !624.00 minimum $ <br /> N PLAN CHECK FEE . !78.00/hour (8 hours mini mm/FACILITY) <br /> R REPAIR FEE (Workplan Review L Construct lon Inspections) TANK I.D. f(a) <br /> E <br /> P TANK LINING REPAIR FEE • f78.00/hour (3 hours minimum/TANK) R TANK(!) __ X !234.00 <br /> A5234.00 mini mum <br /> $ <br /> 1 TANK RETROFIT REPAIR FEE . $78.00/hour (3 hours min./FACILITY) <br /> 1 . 1234.00 minims $ <br /> PIPING REPAIR FEE • 178.00/hour (3 hours minlmLm/FACIU TY) u <br /> N TRANSFERfEE • 120.00 UNAUTHORIZED RELEASE EVALUATION • $78.00/hr 1 <br /> I <br /> S . $78.00/hr <br /> C CONSULTATION FEE 178.00/hr SAMPLING INSPECTION FEE <br /> TOTAL OUIE 1468.00 <br /> FOR OFFICE USE ONLY 77lmmmTTT��R <br /> 1!!11^�d'.L'C0r !m", Y!VAC•11�viil!!3J^J'3:.L'�@-!TT'iP.91!®i^J!3rJliH!°':!u®m11YAVflV:J36ai�3fliVii�'¢mvigYmNnL6VP6�!V Fi 3miaDb"fi: 3'f Wu <br /> SNE EPS f COMPUTER f LOC CODE DIST COO, AMOUNT RECEIVED CHECK f/CASH I RECEIVED BY DATE RECEIVED a!mekm�ewar!srammTnrn,atac�=,°�3'.��!r;!r�!sam�aum>P�arpaommanm. y <br /> — ,.�r./ <br /> EH 23 032 (RPeg@ 11(REVISED I1-1-02) �''fy...rS '.:' <br />