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SAM JOAOUIN COUNTY FUSLIC HEALTH SERVICES - ENVIRONMENTAL <br /> I�ERGROUMD STORAGE TANK PROGRAM - CHTEALiN DIVSi41 <br /> S FACILITY SITE NAME <br /> 1 <br /> ICU' r� �•T 'N FAC LITY CONT CT NAME <br /> E FA ITY ADDRESS <br /> i P E j with AREA CODE <br /> CITY [.F —007 <br /> P E CODE # of TANKS <br /> P APP ICANT/BILLING NAME �dy at SITE <br /> I N N - APPLICANT CATS NAME <br /> C MAILING ADDRESS <br /> A LU IC_ <br /> 7 Cl Y ' LICAN7 PHONE / VI TN AREA CODE <br /> 'w SIO <br /> {Lj MATE P PLICATIgI <br /> (.�� (p (Closure, nstallatim, ate.) <br /> A ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990 TOTAL <br /> T FACILITY PENALTY FEES ASSESSED (If )000 )000( XXXX S <br /> Applicable) 1000( ==XX xxxx <br /> Y TANK FEE : S50.O0/TANK (Prior to January 1,1991) S <br /> E ry S170/TANK (After January 1, 1991) <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F ach year #Tfee for <br /> e <br /> A each year applicable) <br /> C 1( )0�100( )000` <br /> I TANK PENALTY FEES ASSESSED XXX= 7000( X)00( s <br /> L <br /> 1 STATE SURCHARGE - $56.00 each TANK (Due eve 5 5 <br /> T every years) See California H 8 S Code, Section 25287 <br /> T # Tanks x $56.00 1986 through 1990 1991 thr <br /> (Enter arrant and year) ough 1996 <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) Z_ <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours miniaa/TANK) # TANK(s) X 5234.D0 = S <br /> S .7a <br /> U TEMPORARY CLOSURE (Plan Review & Inspecti ors) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hour minimua/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours miniam/FACILITY) = $624.00 minimum 5 <br /> R REPAIR FEE (VorkpLan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimua/TANK) # TANK(s) <br /> A X $234.00 = S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 mininun 5 <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimua/FACILITY) = $234.00 mini" S <br /> MTRANSFER FEE = 220.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> 1 <br /> S <br /> ClCONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE <br /> =EQR_OEEIIa~_41SE�1(1._ Y_- <br /> '�_ iiEFP b FUTEK.__ LUL — T37"� -..A'1'-Ti�CETCi9D 1fEUk' nCA5 EtE7ti l'E�t CETPEB— <br /> y S y <br /> M_ <br /> EH 23 032 (REVISED 4-29-94) Page 11 <br />