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SAN JOAUIN COLIC IC HEALTH SERVICES - ENIYIRONEWAL NERC 'lVSION <br /> _ UNDN Z. STORAGE TANK PROMAN - FEE WEtICRNEET <br /> JFACC LITY SITE NAME FACILITY CONTACT NATE <br /> LITY ADDRESS ITE PHONE S with AREA CODE <br /> 0 L—` C12V 6 A <br /> CITY STATE ZIP CODE 0 of TANKS <br /> A0 at SITE <br /> P <br /> FIAPPLICANTAILLING NAME APPLICANT CONTACT ME <br /> '–T NS — Crtt. <br /> C MAILING ADDRESS APPLICANT PHONE 0 WITH AREA CSE <br /> " 13� 4 Z - 2 <br /> CITY STATE ZIP CODE 1'rmof APPLICATION <br /> IR N A Clasurr, Installation, etc.) <br /> TOTAL <br /> 1986 1987 ! 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) a 3100.00 <br /> xxxx =nl xxxx xxxx xxxx $ bcxxxxxx <br /> FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx 7001, )OIXX XXX, S xxxxxxxx <br /> I <br /> V TANK FEE = 350.00/TANK (Prior to January 1,1991) 5170/TANK (After ianuary 1, 1941) <br /> A Tanks w 1988 1989 1990 1991 1992 1993 1994 1995 1996 11997 1998 <br /> (muttipty 0 by fee for <br /> A each year appticabte) x= XXXx )0= )OOIx xxxx 5 <br /> TANK PENALTY FEES ASSESSED I XXXX X= ,XXX XXX, X= S <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLYY318.50 S <br /> T <br /> auks x 68.00 1968 through 1993 (356) 1993 throto 1997 (356) 1998 <br /> SURCHARGE FOR 1998 xxxxxxxx=OOfXxxx==M= x=x=O=M=xx=O= 3 <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-tri-Place) TANK I.O. 0(s) <br /> O CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # R TANK(s)�+ X SO4.Do s s Cf0 <br /> S <br /> TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. S(s) <br /> TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> INSTALLATION PLAN CHECK (Plan Revter b Construction Inspections) TANK I.D. S(s) <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> IN <br /> Il REPAIR FEE (Workptan Review 3 Construction Inspections) TANK 1.0. Xs) <br /> E <br /> TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) S TANK(s) X $234.00 = $ <br /> TANK RETROFIT REPAIR FEE _ =78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 378.00/hour (3 hours minimum/FACILITY) a 3734.00 minimum $ <br /> TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr s <br /> I <br /> CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 378.00/hr f S <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> SWEEPS IN COMPUTE�LGC DIST CODE AMOUNT RECEIVED �—CHECK N/CASH RECEIVED 3Y DATE RECEIVED <br />-w 71 n7u) topvlsFD 1-12-98) <br />