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SAN JOAQUINZ <br /> IC HEALTH SERVICES - ENVIRONMENTAL HEA* <br /> IVSION <br /> E S7 TANK - FEE KS <br /> S FACILITY SITE NAME FACILITT,Y CONTACT NAME <br /> I � <br /> T <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> b <br /> CITY STATE ZIP CODE # of TANKS <br /> A tLYN at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> 1 <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A �� �q ld�� C S <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLI� � ,.T <br /> (Closure, stallation, etc.) <br /> TOTAL <br /> 19 1987 119 11489 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A XXXX XXXX I XXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX xxxx XXXX I XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks = 19W 1989 1990 1991 1992 1993 1994 1995 1996 11997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx XXXX xxxx XXXX XXXX $ <br /> Cl <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX xxxx XXXX I , S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=S18.50 S <br /> T <br /> Y # Tanks x $8.00 1988 through 1993 ($56) 1493 through 1947 (S56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXxxxxxxxxxxxxxxxxxx XXXXXxXxxXXxxxxxxxxxxxX $ <br /> C PERMANENT CLOSURE (R vat or Authorized Ctosure-in-Ptace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours mini /TANK) # TANK(s) X S234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours mini /FACILITY) S234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours mini /FACILITY) = $624.00 minimum S <br /> R REPAIR ,FEE (Workplan Review & Construction Inspections) I TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours mini /TANK) TANK(s) X 4.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = $78.00/hour (3 hours mini /FACILITY) _ $234.00 minimum $ <br /> rI <br /> TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S <br /> TOTAL DUES <br /> FOR OFFICE USE ONLT : <br /> ... ..,_...«...«............ .::^•::::•::-s::•ra::::c::ra:::^•a:�c.:.^..:.^..::a•::^s:sn.....r•.ra...«^-u^�e-.•:s.—.«...«.«.....:::r..^:.•••: qe ea:• .^..r.:z••:arz .—^-^r.:s::.•s:�•:a .... �"«^.•e••.^_.::.•-:r.:x.�::::—_.._r.: Egg ...::r.:•� <br /> .:tt.....-:ar..........�.....:::•::�_r—as..: s..a....._..«....»«......n.«.«.£............a....._..: .:: <br /> :e.:r.•=ec:s.•::'uiu:FFe:�a::s::ruvioem:a:ws::::z:es::::::::a::We: ME.:su.:: ::x::s:_::-".s•»::.::cc:::av::::•r.:a�a.tt•...•...._••.•:aucn:::..._«..s.:::=..::«aEz=.:.�is_::�e•.e:»�:::�zia:e�:«:�=-=iz�i:�^e::-: <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> -: — <br /> :II <br /> s22 _ <br /> ... ....................... ................._.«.«............».«....................................«.........»_...._...........�..._....«..................._...................__......:c::�.r.�.«:d..cn::�«:••:::T�...:..�.....�....___:c:.:::::::�s::�::::::::::-:rr.�:::s:_.e._,e <br /> Fu a� (n';? rRFVTSFD 1-12-98) <br />