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SAN JCAOUIN M9 PUBLIC <br /> HEALTH SERVICES <br /> P12CCG - ENVIRONMENTAL EEWOQMX <br /> SI FACILITY SITE HAME U1mERG2C(N¢I STORAGE TANK PROGRAM - FEE WCIRICSNEET DIVSIC�N <br /> I� <br /> � FACILfT�CrNTAC7 NAME <br /> e ,` 0 , e % ) <br /> E FACILITY ADDRESS `�Q/V <br /> L SITE PHONEG; vi EA CODE <br /> P Cltt �—, /� JZj STATE ZIP CODE <br /> �"/7CLL _ a at TANKS <br /> P APPLICANT/BILLING NAME at SITE <br /> L <br /> I APPLICANT CONTACT NAME <br /> C NAILING ADDRESS <br /> A <br /> N I APPLICANT PHONE Y WITH AREA CODE <br /> T CITY <br /> STATEN ZIP CODE TYPE of APp <br /> L[GTION ��✓ � <br /> (C(oswe, Instatlatien, etc.) <br /> S <br /> ANNUAL FACILITY FEE (Prior eo January 1, 1991) = 5700.00 TOTAL <br /> A 19 1987 1988 I 1989 1990 1 C+f� O O <br /> C CC X <br /> T FACILITY PENALTY FEES ASSESSED 1 O D <br /> I (If Applicable) I S Q Q °� <br /> V TANK FEE = 550.00/TANK I )C= <br /> E o ry 111991) <br /> i Tanks a 5170/TANK (After !a <br /> ry ,, 1991) 7 <br /> ,986 987, 1488 11989 11990 1199, 11992 11993 11994 11995 11996 <br /> F (multiply ^< by fee far v <br /> A each year applicable) XXXX XXXX �J (/ <br /> I TANK PENALTY FEES ASSESSED I XXXX I XXXX O I 7 v�'7 D I I S O O <br /> L O <br /> I STATE SURCHARGE = $56.00 each TANK (Due eve I' 4 D I S <br /> T every 5 year See California H ; S C <br /> T 9 Tanks� 556.00 I ode, Section 25287 <br /> (Enter amount and 1988 through 1990 <br /> year) 1991 through 1996 <br /> O <br /> ra <br /> C PERMANENT ;;.SURE (Removal or Authorized Closure-in-P(ace) <br /> L TANK I.D. y(;) <br /> OI CLOSURE FEE578.00/hour (3 hours minimui'TANK) <br /> S 7ANK(s)� X 5234.00 = <br /> Ul iEMPCRAR7 CLOSURE (Plan .Review i (nspettims) S <br /> R I TANK I.D. ,Y(s) <br /> E iE.MPCRARY CLOSURE FEE - 378.00/hour (3 hours .miniaAm/FACILITY <br /> ;234.UU .minimum <br /> I S <br /> PI INSTALI.ii:CN PUN CHECX ;Plan Review 3 Constvction fnspeczions) TANK [.D. ;(;) <br /> LI <br /> A <br /> N PUN CHECx FEE 578.00/hour ;8 hours minimAm/FACILItt) <br /> = S624.00 minimus <br /> cA <br /> R 2EPA1R F'cE (Workplan Review i Certstructian Inspection) TANK l.D. 4(s) - <br /> E, <br /> P "AHK ..MING REPAIR FEE = 5;8.00/hour (3 hours minimLcVTANK) I Y TANK(s) X 5734.00 = ; <br /> A <br /> 578.00/flour (3 hours min./FACILITY)TY) = 3 6. <br /> R 23 00 minimus S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimLWFACILITY) <br /> = 2234.00 minimuP S <br /> Al iRANSFE.R FEE = 520.00 UNAUTHCRI-" RELEASEE EVALUATION ; <br /> I = 78.00/hr I S <br /> 5 I <br /> C� CONSULTATION FEE = 578.001hr I I _ <br /> SAMPLING INSPECTION FEE = 278.00/hr <br /> S <br /> FOR OFFICE USE CRL7 TOTAL DUE S <br /> SWEEPS S COMPUTER _ LOC CCOE DIST CODE AMOUNT RECEIVED CeECX /CASN RECEIVED 37 DATE RECEIVED = <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />