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SAN JOAQUIN 0--TY PUBLIC HEALTH SERVICES - ENVIRMOMAL jr ''H OIVSION <br /> LA1111DUMD STORAGE TANK .ORoGRAH - FEE <br /> S1 FACILITY 'T_= 4 e ! FACILITY TACT NAM <br /> T; <br /> EI FACILITY ADDRESS SITE PHONE »` with A CODE E <br /> PAO <br /> 8 s <br /> CITY I STATE] ZIP ME j of TANKS <br /> Ai ! II at SITE t <br /> P' n <br /> P APPLICANT/SILLING N E APPLICANT CONACt ° <br /> I <br /> Ci MAILING ADDRESS I APPLICANT P : WITH AREA CODE <br /> A� r D -- 41( <br /> ° TjCITY STATE ZIP E TYPE of APPLICATION E <br /> i 1 COD <br /> �- s- (Closure, installation, etc.) f <br /> TOTAL <br /> 1986 1967 , 1988 ' 1989 ( 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A p XXXX XXXX XXXX i XXXX XXXX ; S xxxxxxXX <br /> C <br /> Tj FACILITY PENALTY FEES ASSESSED Of Applicable) I =a I X.YM ( XXXX , XXXX I VM S XXXXXXXX ° <br /> VI TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E' <br /> Tanks = , 1987 1988 1 1989 1 1990 1991 1 1992 1199; 1994 1995 11496 1997 e <br /> F (multiply A fee for <br /> C� each year axs(icab(e) 4 XXXX , )=X I XXXX I )0= IXXXX 1 I 1 1 + S 5 <br /> I) TANK PENALTY FEES ASSESSED I XXXX I )0= ( XXXX I XXXX IXxxX I i I I 1 I 1 <br /> I <br /> II STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 i5 <br /> T <br /> j Y1; # Tanks x 58.00 , 1988 through 1990 CS56) 1991 through 1996 CS56)� 1997 <br /> I <br /> SURCHARGE FOR 1997 xxM=xM=xxx==xxxxxxx � X � � S <br /> C1 PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. R(s) tr <br /> L. <br /> j <br /> Of CLOSURE FEE = S78.DD/hour (3 hours minimum/TANK) I R TANK(s) X 5234.00 = S 6 <br /> S. <br /> ! U! TEMPORARY CL=R_E Celan Review & Inspections) 1 TANK I.D. :(s) <br /> R` i <br /> El TEMPORARY CLOSURE FE. = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> sif INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. T(s) <br /> i A�NI PLAN CHECK FEE = S78.00/hour C8 hours minimum/FACILITY) = 5624.00 minimum ( S <br /> RREPAIR FEE (Workplan Review L Construction inspections) ( TANK I.D. #(s) <br /> s E <br /> PI TANK LINING REPAIR FEE = 578-00/hour (3 hours minimum/TANK) I R TANK(s) X S234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum s.23 <br /> �J c/. o® <br /> R� dJ T <br /> PIPING-REPAIR FEE = S78.00/hour C3 hours minimum/FACILITY) = S234.00 minimum S <br /> MI TRANSFER FEE = S20.00 1 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I S <br /> Si 1 B <br /> C. CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = S78.00/hr l i S 9 <br /> TOTAL DUE 5 tl� 01j e <br /> FOR OFFICE USE ONLY T <br /> 9 O <br /> SUEEPS ". ( COMPUTER # I LOC _—DE i DIST CODE ! AMOUNT RECEIVED I CHECK #/CASH � RECEIVED 3Y I DATE RECEIVED - <br /> _ S i i <br /> =H 23 032 (REVISED 5-27-97) _-�_ <br />