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SAN JOAQUINTY PUBLIC HEALTH SERVICES - ENVIRONNENTAL&TH DIVSION <br />RGROUMn SWRAM TAWC ootv_oar - eee ir%ovou <br />I <br />FACILITY SITE NAME <br />'S 1ac_i ! I) ►moi <br />FACILITY CONTACT NAME <br />T <br />A <br />sir- ts. b, <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />& <br />1 l0 5 eDo l= L-� sre� <br />2r- 3 -i & 3 - 0 --:?. "�- 1 <br />P <br />CITY <br />L4- <br />STATEI <br />'� <br />ZIP CODE <br />'-�1 o <br /># of TANKS <br />at SITE <br />1988 <br />1989 1990 <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />XXXX <br />XXXX <br />P <br />La <br />APPLICANT/BILLING NAM <br />APPLICANT CONTACT NAME <br />I <br />T=- �� s <br />I�>� �—►� i 1 n�� r <br />C <br />A <br />MAILING ADDRESS <br />Z z%:� LOQ, <br />APPLICANT PHONE # WITH AREA CODE <br />N <br />�ti,r „�• <br />�1 (' C"35 Zti �-1Ll <br />T <br />CITY <br />D✓3 <br />STATE <br />Ley <br />ZIP CODE <br />-IL z <br />TYPE of APPLICATION <br />(Closure, Installation, etc.),,,-�) <br />C <br />PERMANENT CLOSURE emova or Authorized Closure -in -Place) <br />TANK I.D. #(s) L-!,tJ k -J.0 N <br />L <br />A <br />tE <br />0 <br />S <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) l X 5234.00 <br />TOTAL <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />ANNUAL FACILITY FEE (Prior to January <br />1, 1991) = <br />$100.00 <br />= $234.00 minimum $ <br />1986 <br />1987 <br />1988 <br />1989 1990 <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />XXXX <br />XXXX <br />XXXX <br />$ <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If <br />Applicable) <br />XXXX <br />XXXX <br />xxxx <br />$ <br />I <br />V <br />TANK FEE = 550.00/TANK <br />(Prior <br />to January 1,1991) <br />$170/TANK <br />(After <br />January <br />1, 1991) <br />E <br /># Tanks = <br />1986 <br />1987 1988 <br />1989 <br />1990 1991 1992 <br />1993 <br />1994 <br />1995 1996 <br />F <br />(multiply W-6-y—fee for <br />XXXX <br />XXXX XXXX <br />$ <br />A <br />each year applicable) <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX XXXX <br />$ <br />L <br />I <br />STATE SURCHARGE _ $56.00 each TANK <br />(Due every 5 <br />years) <br />See California H & S <br />Code, <br />Section <br />25287 <br />T <br />Y <br /># Tanks x $56.00 <br />1986 through <br />1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />C <br />PERMANENT CLOSURE emova or Authorized Closure -in -Place) <br />TANK I.D. #(s) L-!,tJ k -J.0 N <br />L <br />A <br />tE <br />0 <br />S <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) l X 5234.00 <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum $ <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum $ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />E <br />A <br />P <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br />$ <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections)TANK <br />I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimun/TANK) <br /># TANK(s) X $234.00 = $ <br />A <br />I <br />TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum $ <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum $ <br />M TRANSFER FEE = $20.00 <br />I — <br />S <br />C CONSULTATION FEE = $78.00/hr <br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />SAMPLING INSPECTION FEE _ $78.00/hr <br />TOTAL DUE <br />EH 23 032 (REVISED 4-29-94) Page 11 <br />$ <br />$ <br />