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SAN JOAOUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH DIVISION <br /> pU� STORAGE TANK PROGRAM - FEE <br /> FACILITY CONTAJ=, <br /> IFACILITY'-z SI?E NAME <br /> FACILITY <br /> LITYY-c'' / �� ��PHONE <br /> E FACILITY AOORESS �/ C�r q <br /> & y b ATEI ZIP I : of TANKS <br /> CITY at SITE <br /> A <br /> p �� I APPLICANT ACT NAMJy <br /> P APPLICANT/ L N <br /> /�/ PLICANT FICHE -. YITH AREA CODE <br /> I <br /> C MAILING ORES _ , lot <br /> r0 <br /> A �`7 " <br /> N STATEN CODE�a I TYPE of APPLICATION <br /> T C VCII (Closure, Ins tallatian, etc.) <br /> TOTAL <br /> 1986 11987 11988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 xxxx xxxx I XXXx I )0= I 'a S XXXXXx x <br /> T FACILITY PENALTY FEES ASSESSED (If ApplioaoLe) <br /> XX XXXx I Xx(x I )C= I xXX% S <br /> I S,70/7ANX (After January 1, 1991) <br /> V TANK FEE = SSO.00/TANK (Prior to January 1,1941) <br /> E 1986 11987 11988 11989 11990 11991 11992 17993 I 1994 11995 11996 <br /> " Tanks = I I I I I S <br /> "r (mAltipLY = by fee for XXXX I )OCa I XXXX I X)= I � <br /> A each year am icacle) I I I I S <br /> I TANK PENALTY FEES ASSESSED <br /> �« =cc xxxx xxxx XXxx <br /> LSSo.00 eac� TANK (Due every, 5 years) See California H & S Code, Section 25287 <br /> I STATE SURCHARGE _ <br /> T 1988 through 1990 1991 through 1996 <br /> Y : Tanks x 556.00 I S <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Autnori zma Cl osure-in-Place) I TANK I.D. .(S) - S <br /> L : TANK(S)__ X S23L.00 <br /> 0 CLOSURE FEE = S78.00/hour (3 hours mtmmAmrANK) <br /> STANK I.O. :(S) <br /> Ul TEMPORARY CLCSURE (?Lan Review i lrecec:ions) I S <br /> R = 573.00/hour G hours minimuNFACI LITY) I 523L,00 mi ninam <br /> EI TEMPORARY CLOSURE FEE <br /> Pi INSTALLATION PLAN CHEC: (Plan Review 3 Cons:ruz ion lns0ec:i0n5)I TANK I.O. :(S) <br /> L S <br /> Al <br /> = 56Z4.00 minimum <br /> N1 PLAN CHECK FEE = 578.00/t cur CS hours minimuNFACI LITY) <br /> i <br /> RREPAIR FE. (Vorkplan Review & Cars: :c <br /> n :i an Inspections) TANK I.D. #(S) <br /> I I <br /> E _ I iANK(S) _� x SZ34.00 = S <br /> = S711 00/hcur (3 hours minimm/TANK) <br /> pl ANK LINING RE?A1R "- S <br /> Ai _ S234 00 minimum <br /> I TANK- RETROFIT R_zAIR FEE - 578.00/hour (3 hours min./FACILITY) 15 <br /> Rr = S231,00 minimum <br /> PIPING RE.-AIR FE = 578.00/hcur (3 hours mtnimsN/FACI L.iY) <br /> M TRANSFER FEE = S20.00 I I UNAUTHORIZED RELEASE EVALUATION = 573.00/hr <br /> S <br /> I I <br /> S E = Si3.00/hr I I 5 <br /> C CONSULTATION FE = 578.00/hr I I SAMPLING INSP_GION FEE S �C� <br /> TOTAL OLE <br /> FOR OFFICE USE ONLY --- -- - <br /> - u - <br /> �nE i AMOUNT RECEIVED HECK /CASH RE VEO 3Y <br /> SyE_?5 tl I COMPUicR Luc. uue I °�'• '"- <br /> j S _ ! ��— <br />