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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSIOI <br /> UNDERGROUND STORAGE TANK PRO7RAN - FEE NoRKS11EEi <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1 7Rr 17 T L an Tot�)KC E . !1•wlc <br /> T <br /> E FACILITY ADDRESS SITE PHONE N with AREA COD ' <br /> $ 3�ai w 33 a0q- 865 -0XV, <br /> CITY STATE ZIP CODE N of TANKS r~i1NFC� <br /> A / ' �• Q�3�o at SITE pAJE RECEIVED <br /> P APPLICANT/BILLING NE APPLICANT CONTACT NAME JA N 1 1 1993 <br /> L .SAME As ABo�E <br /> I cA! <br /> C MAILING ADDRESS APPLICANT PHONE d WITH AREA p"t.1C HEALTFI SERVIC c <br /> A ENVIRONMENTAL HEALTH DIV 5 <br /> N <br /> i CITY STATE ZIP CODE TYPE of APPLICATION �7 <br /> (Closure, installation, etc.) I?F goVA L- <br /> TOTAL <br /> 1986 1987 1988 1989 , 7990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 1100-00 , <br /> A _! <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X%%% XX%X $ <br /> 1 <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 2170/TANK (After Jill 1, 1991) <br /> E <br /> 0 Tanks = 1986 1987 1988 1989 J19901991 1992 1993 1994 1995 1996 <br /> LIARKPINALTY <br /> y W-&y fee for <br /> r applicable) X <br /> $ <br /> ALTY FEES ASSESSED Kx%% X%K%RCHARGE + $56.00 each TANK (Due every 5 years) See California H E S Code, Section 25287 <br /> , s 056.00 1986 through 1990 1991 through 1996 <br /> amount and year) $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK 1.0. A(a) - O'er <br /> 6 1L <br /> 0 CLOSURE FEE + $78,00/hour (3 hours minimum/TANK) N TANK(s)�_ X $234.00 = $ 2 w <br /> S <br /> U TEMPORARY CLOSURE (Plan Review b Inspections) TANK I.D. N(a) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) N TANK(s)— X $234.00 $ <br /> P INSTALLATION PLAN CHECK (Plan Review A Construction Inspections) TANK I.D. Ole) <br /> L <br /> A $ <br /> N PLAN CHECK FEE _ %78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum <br /> R REPAIR FEE (Workplan Review 6 Construction Inspections) TANK I.D. M(s) <br /> E <br /> P TANK LINING REPAIR FEE e 518.00/hour (3 hours minimum/TANK) M TANK(s) _ X 5234.00 % <br /> A 9 <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minlmun/FACILITY) 5234.00 minimum $ <br /> H TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION + $78.00/11r $ <br /> S <br /> C CONSULTATION FEE _ $78,00/hr SAMPLING INSPECTION FEE = $78.00/hr $ : <br /> TOTAL DUE Ij q04'/.W <br /> FOR OFFICE USE ONLY m rn!n!mmneunm!nurr,inn nun muninn nnm!!snn!mnm rn nunnni nllnnn;nnnm;pii,_. <br /> ,�!.!!!: :::.L... .....! <br /> I MHU I .:HW ;!..I�I.! <br /> nim nnn:n.,n..l. <br /> • <br /> ...!....... <br /> SWELOC CODE DIST CODE RECEVED CIIECK N/CASH RECEIVED BY DnATE RECEIVED <br /> ! <br /> I <br /> E <br /> n!unan ni <br /> ! :m!n!nn nmmnre!!! <br /> .! nm !I !n n nnmu! m : .n nn nm.!m n! ! m!mp!nm;n!n!mnm mm�unr!I;np !nnn!mm�m!;Iq;rculnplr nm!!Ilmnw rm.:: ,;;:;�!:;!!in!;;;;:nx:!v,;!!!!��: <br /> �!°"rl°h""I"!mNll�ll✓nN�m6�17�!�I!1A!nlmRPll!n!m�l�!N: a!!!.!-!n . . <br /> FH 23 032 (REVISED 11-1-92) / I,� n,K3 mge 11 • <br />