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SAN JOAOUIN PUBLIC HEALTH SERVICES - EmRomawrAL DIVISION <br /> STORAGE TANK PROQMI - FEE <br /> SI FACILITY SITE NAME <br /> I /� � I FACILITY CONTACT NAME <br /> \/ <br /> T <br /> E FACILITY <br /> ADDRESS SITE PHONE With AREA <br /> & EO E <br /> 9 <br /> CI 7 T TE ZIR BOE ? of TANKS <br /> A <br /> Pitw Yoh C-1�`0 at SITE <br /> P APPLICANT/BILLING NAME I <br /> L !CANT CONTACT N <br /> I <br /> C MAILIN ADORESS APPLICANT RHONE : WITH AQZ AR A CODE <br /> A <br /> M <br /> T CIT STATEI P Tj _ I (CLosuf APPLIInSCATION an, etc.) <br /> TOTAL <br /> 1 <br /> ANNUAL FACILITY FEE (Prier to January 1, 1991) = 5100.00 1986 11987 1988 11989 11990 <br /> XXXX I )D= I XXXX I )0= I . = xx XXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXL I xxxx I )CCa I rm I xxxx 5 <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 51701TANK (After January 1, 1991) <br /> E <br /> Tanks 1986 11987 11988 11989 11990 1991 11992 1993 11991 11995 11996 <br /> F (nul:ip(y oy fee for <br /> A each year applicaote) XXXX XXXX I XXXX <br /> C I =,xX I XXXX I I I I S <br /> I TANK PENALTY FEES ASSEESSED = I S I X I '� I XXL I I S <br /> L <br /> I STAT-c SURCHARGE = $56.00 each TANK (Due every 5 years) See Ca[ifonia H & S Code, Sec:ivn 25287 <br /> T <br /> Y - Tanks z 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> I5 <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK 1.0. :(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimam/iANK) I TANK(s) X <br /> S 5234.00 = 5 <br /> U TEMPORARY CLOSURE (Plan Review & Irepec:i ors) I TANK I.0_ :(s) <br /> RI <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours miniffamVFACILf TY) I 5234.00 minimus I S <br /> PI INSTALLATION PLAN CHECK (PLan Review & Carstruc;ion Inscec;i ars 7l TANK L.D. d(s) <br /> L <br /> A <br /> N PLAN CHECK F- = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimus S <br /> i <br /> RI REPAIR F==E (VorimLan Review & Construction Inspections) I TANK L.D. *(a) <br /> c <br /> P TANK LINING REPAIR F_£ = 578.00/hour (3 hours minisa.WTANK) I TANKCs) X 5234.00 = 15 <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hwr (3 hours min./FACILITY) - 5234.00 minimm 5 <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minim m/FACIL17) = 5234.00 minis 15 0 <br /> N TRANSFER FEE = 520.00 I I UNAUTHORIZED REUSE EVALUATION = 578.00/hr I I S <br /> I <br /> S <br /> C CONSULTATION F- = 578.00/hr I I SAMPLING INSPECTION FEE = 578.00/hr I S <br /> TOTAL DUE 5 <br /> FOR OFFICE USE JILT <br /> SWEEPS COMPUTER + LOC COLE OIS, CODE AMCUNT RECEIVED CHECK 7/GSHRECEIVED 3Y DATE RE'-IVED <br /> S <br />