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SAN JOAQUIN COLjTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL WALTH OIVStOM <br />°GROW STORAGE TANK PROGRAM - FEE BEES <br />S FA ITYSIT NAME FAC�T ILTY CONTACT NAME (® <br />T aYl ( d �f VC, <br />E FACILITY ADDRESS c <br />SITE PHONE # with AREA COOS <br />0 <br />S <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) -7- X 5234.00 =06 <br />CITY <br />A 'lii <br />� <br />FQ44- <br />ZIP CODE <br /># of TANKS <br />SITE <br />P <br />V TANK FEE = SSO.00/TANK (Prior to January 1,1991) 5170/SANK (After January 1, 1991) <br />E <br />0 Tanks = <br />F (multiply # by fee for <br />at <br />P APPLICANT/BILLING NAME <br />L <br />APPLICANT CONTACT NAME <br />I <br />1990 1991 1992 <br />C MAILING ADDRESS <br />A <br />APPLICANT PHONE # WITH AREA CODE <br />N <br />T CITY <br />TATE <br />p <br />ZIP CODE <br />'— <br />TYPE of APPLICATION (� (/^ <br />A each year applicable) <br />C <br />(Closure, Instattation, a c.` <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S10D.00 <br />1986 <br />1987 1988 1989, 1990 <br />A <br />0 <br />S <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) -7- X 5234.00 =06 <br />C <br />U <br />s <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX <br />I 5 <br />V TANK FEE = SSO.00/TANK (Prior to January 1,1991) 5170/SANK (After January 1, 1991) <br />E <br />0 Tanks = <br />F (multiply # by fee for <br />1986 <br />1987 <br />1988 <br />[ 1989 <br />1990 1991 1992 <br />1993 1994 1995 <br />1946 <br />A each year applicable) <br />C <br />$ <br />I TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />L <br />$ <br />I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California N b S Code, Section 25287 <br />T <br />T 9 Tanks x $56.00 <br />(Enter amount and year) <br />1986 through 1940 1991 through 1996 <br />S <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #<s) - O1A j It-( <br />L <br />A <br />0 <br />S <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) -7- X 5234.00 =06 <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />R <br />S <br />El <br />TEMPORARY CLOSURE FEE a 578.00/hour (3 hags mini TANK) # TANK(s) X 5234.00 a <br />S <br />SAMPLING INSPECTION FEE <br />a 578.00/hr <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.O. #(s) <br />A <br />I TANK RETROFIT REPAIR FEE a 578.00/hour (3 hours min./FACILITY) <br />R <br />N <br />PLAN CHECK FEE a $78.00/hour (8 hours miniMWFACILITY) a 5624.00 minimum S <br />R REPAIR FEE (Workplan Review & Construction Inspections) <br />E <br />TANK J.D. #(s) <br />P TANK LINING REPAIR FEE = 578.00/hour (3 hours mini TANK) <br />A <br />0 TANK(s) X 5234.00 = S <br />I TANK RETROFIT REPAIR FEE a 578.00/hour (3 hours min./FACILITY) <br />R <br />a $234.00 minimum S <br />PIPING REPAIR FEE a 578.00/hoar (3 hours: minimum/FACtLITY) <br />= 5234.00 minimum 5 <br />M TRANSFER FEE a $20.00 <br />I <br />UNAUTHORIZED RELEASE EVALUATION a S78.00/hr S <br />S <br />C CONSULTATION FEE a 578.00/hr <br />SAMPLING INSPECTION FEE <br />a 578.00/hr <br />FOR OFFICE USE ONLY <br />HMO8 <br />SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVEp CHECK #/CASH <br />-� GO a s <br />EH 23 032 (REVISED 11-1-92) Page 11 <br />RECEIVED BY I DATE RECEIVED <br />