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SAN JOACAJIN — TY PUBLIC HEALTH SERVICES - EXVIRCNMENTAL HEALm DwSION <br /> GROUND STORAGE TANK PROD M - FEE 41=SH <br /> SI FACIL,I7-7 SITE NAMEFACiLIT7 CONTACT NA <br /> C 91t .1A 'C WL CO,O, <br /> T VI <br /> -Ei FACILITY ADDRESS SITE PHO E " 'Ai:h AREA CODE <br /> CITY STATEZIP CODE T of TANKS <br /> i <br /> A CA I r`�al at S I T E <br /> P S b G*<To rj ] <br /> P APPS-(CANT/BILLING NAME APPLICANT CONTAC-, NAME <br /> - he <br /> C MAILING ADDRESS I APPLICANT PHCHE " WITH AREA CODE <br /> A jyo <br /> N , �D SAn,s <br /> 7 CITY STATE ZIP CODE YPE of APPLICATION?pI Vl cAocsme <br /> ST �✓ CA R y j (Closure, Installation, etc. <br /> TOTAL <br /> 1986 I 1987 1988 1989 � 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX I xXXX XXX)( XXxX XXXX S XXXXXxxx <br /> e <br /> TI FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx I XXXX xXXX I XX)(X XXXX 5 XXXXXXXX <br /> If <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) I 5170/TANK (Atter January 1, 1991) <br /> E I <br /> Tanks = 1988 11989 11990 1991 ! 1992 11993 11994 11995 1996 11997 11998 <br /> F (multiply 9 by fee far ! <br /> A each year applicable) XXXX I XXXX XXXX I XXXX (XXXX I I I S <br /> C' <br /> I iANK PENALTY FEES ASSESSED XXXX I XXXX I XXXX I XXXX XXXX ' I I I I 5 <br /> L' <br /> I STATE SURCHARGE FOR NE.f FACILITIES ONLY=118.30 <br /> T <br /> Y Tanks x 58.00 1988 :hrcugh 1993 (556) 1993 through 1997 (S56)I 1998 <br /> SURCHARGE FOR 199$ xxxxxxxxXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX i I S <br /> Cf PERMANENT CLCSURE (Removal or .authorized Closure-in-Place) I iANK (.O. T(s) LrC ff Ad "1 f6;,3 1D <br /> L• <br /> O C QS FEE = S78.00/haur (3 ;tours minimumr/7ANK) I : TANK(s) ti X 5234.00 <br /> 5 <br /> U TEMPORARY CLOSURE (Plan Review 3 Inspections) I TANK I.O. #(S) <br /> R <br /> E, TEMPORARY CLOSURE FEE = S-78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan .Review L Construction InspeVtiens)I TANK I.D. T(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 378.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R� .REPAIR FEE (Workplan Review 3 Construction Inspections) TANK i.0. ;0(s) <br /> E <br /> PTANK LINING REPAIR FE=- = 578.00/hour (3 hours minimum/YANK) I # TANK(s) X 5234.00 = � 5 <br /> A <br /> 11 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimtm 5 <br /> R <br /> ?(PING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum 5 <br /> Mi TRANSFER FEE = 520.0 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I 5 <br /> S; <br /> Cl CONSULTATION FEE = 578.CC/hr I SAMPLING INSPECTICN FEE = S78.00/hr I S <br /> TOTAL DUE V34 00 <br /> FCR OFFICE USE ONLY <br /> SWEEPS 4 I COMPUTER 4—I LOC CODE DIST CODE I AMOUNT RECEIVEO_I CHECK ,/CASH I RECEIVED BY I DATE RECEIVED <br /> I IS I i f <br /> 1.4 23 032 (REVISED 1-12-98) <br />