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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UN' MOUND STORAGE TANK PROGRAM - FEE WORK39FET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T iC �'E�v <br /> E FACILITY �/ SITE PHONE 1 with AREA CODE <br /> 1 z ADORE7f Nam v - - . , - - G,e� <br /> CITY lA l\•I STAT ZIP CODE 1 of TANKS \ <br /> A -ro A c et SITE Cz ) ELF- . <br /> P <br /> P APPLICA 2L=NATE _ APPLICANT CONTACT MANE <br /> o o b z /e. P,c /�. �✓ <br /> C NAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> M <br /> I CITY SSTAT! ZIP CODE TYPE of APPLICATION Ae�r��, ,�i✓�o 9 BzS ter., 1„t4ll.tlon, etc.) <br /> TOTAL <br /> 1966 1967 1908 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to Jewry 1, 1991) 1100.00 <br /> A 1 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) KKI(% %100( 1 <br /> 1 <br /> V TANK FEE • 350.00/TARK (Prior to Jeruary 1,1991) 5170/TANK (After January 11 1991) <br /> E <br /> / ranks a 1986 1967 1966 1989 1990 1991 1992 199] 1994 1995 19% <br /> F (nultlply Thy fee for <br /> A each Year $ppllteble) <br /> t 1 <br /> I iARK PENALTY FEES ASSESSED K%%% Tom 1 <br /> L <br /> 1 STATE A/RCHARGE • $56.00 each TANK (Due every 5 year$) SN Cel lfornio H L 3 Code, Settlor 25267 <br /> T <br /> T 1 Tanks A 156.00 1966 throtph 1990 1991 throuO 1996 <br /> (Suter rant and year) <br /> s <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-In-Plate) TANK LD. 1(a) <br /> L <br /> O CLOSURE FEE + 378.00/hour (3 hotre minioLm/TANK) 1 TANK($)_1, K $231.00 <br /> 7 . S OD <br /> U TEIPoRMT CLOSURE (Platt Review i IMpettloM) TANK I.D. 1(a) <br /> R <br /> E TEMPONARY CLOSURE FEE • 178.00/hour (3 h0trl MlnfwWFACILITY) a 123!,.00 sInlam ! <br /> P INSTALLATION EMDO/h" <br /> lan Rw1ew E CtNtatruttlon (Mpeetltxu) TANK I.D. IO1 <br /> LA <br /> N Pt AN CHECK FE (8 hours einleaAA/FACILITY) r 1621.00 MInIMUR 1 <br /> R REPAIR FEE (Workplan Review E COM traction iMpactiOM) TANK I.D. 1(Q <br /> E <br /> P TANK LINING REPAIR FEW • !78.00/hour (3 hour• MIn1eWTANK) / TANK(*) <br /> A _ % 3231.00 . t <br /> I TANK RETROFIT REPAIR FEW a 578.00/hour 0 hour$ min./FACILITY) 2231.00 ■Inieaw 1 <br /> R <br /> PIPING REPAIR FEE a 378.00/hour (3 hours minieue/FACILITT) . 1231.00 mint" 1 <br /> M rRARiflR itW • !20.00UTAUTHONIZEO RELEASI EVALUATION + S78.00/hr 1 <br /> I <br /> S <br /> C CONSULTATION FIFE • 178.00/hr SA)OR.INO INSVEC 11011 FEE EC /hr <br /> Y 1 p igg3 TOTAL DUE <br /> FOR OFFICE USE ONLY SANJOAQUINCO <br /> � <br /> L-c—��� Ai.TA��i.•��� �s+��,,:.r�aoc.»o C.YN�C.z..—i �.:zr;z��c A3i.�A3GR:3>3�ii <br /> rr•:arar rrwemerrerAMrlM+rrNlm wrrrmrreawraer NR aemreatrwreamee rAtrrrerr rAawrAaeeM+rrmrr <br /> EN 23 M (IHIMAO 3.1-93) Paas 11 <br />