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SAN JOAOUIN Cr14TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL DIVSION <br />WRO STORAGE TANK PR=AM - FEE WORKSISM <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />0 S Lo'AL— <br />THY PH- ,J <br />T <br />1990 <br />E <br />FACILITY ADDRESSS <br />TE P # with AREA CODE <br /># TANK(s) X 5234.00 = <br />$ <br />>ob , 5- 35 <br />S <br />A <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />—� C <br />R <br />y 5 �`� <br />at SITE <br />P <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum S <br />P <br />APPLICANT/BIL ING NAME <br />APPLICANT CONTACT NAME <br />1 d S S UL \ l� 5 <br />l C -,GE <br />I <br />T <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />XXXX <br />g 5u���5� �L_V� <br />I XXXX S XXXXXXXX <br />N <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />V <br />C U U uv <br />5170/TANK (After January 1, 1991) <br />5 <br />(Closure, Installation, etc.) <br />TOTAL <br />PERMANENT CLOSURE (Removal 'or Authorized Ctosure-in-Place) <br />TANK I.D. #(s) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />$ <br />S <br />A <br />U <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX $ XXXXXXXX <br />R <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum S <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX <br />XXXX <br />( XXXX <br />I XXXX S XXXXXXXX <br />I <br />V <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks = <br />1987 <br />1988 <br />1989 ( 1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 11996 <br />1997 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />XXXX <br />XXXX <br />XXXX XXXX <br />XXXX <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX <br />XXXX <br />I XXXX XXXX <br />XXXX <br />5 <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 IS <br />T <br />Y <br /># Tanks x $8.00 <br />1988 through 1990 (S56) <br />1991 through 1996 (S56) <br />1997 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXX]OOOOO ODO(X <br />S <br />SURCHARGE FOR 1997 <br />C <br />PERMANENT CLOSURE (Removal 'or Authorized Ctosure-in-Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />$ <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 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 minimum/FACILITY) = S624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) Z 3 oa <br />E <br />P <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/ FACILITY) = S234.00 minimum <br />S <br />M TRANSFER FEE = S20.00 <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr <br />FOR OFFICE USE ONLY <br />SWEEPS # COMPUTER # I LOC CODE <br />EH 23 032 (REVISED 5-27-97) <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />DIST CODE I AMOUNT RECEIVED I CHECK #/CASH <br />Is <br />S <br />S <br />TOTAL DUE S <br />RECEIVED BY I DATE RECEIVED <br />