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0—.di 1:1;�20 1 :4O V1141 r rttJrvl ra_ 4 <br /> SAM JOAQUIN CAALIC HEALTH SERVICES - ENV( AL ION <br /> UN WIND STORAGE TANK PROOM FES WORIMEET <br /> S FACILITY SITE NAR FACILITY CONTACT <br /> I <br /> _ (L <br /> E FACILITY ADDRESS SITE PHONE S with AREA CODE <br /> Hc)CI 3 a <br /> CITY STATE ZIP CODE ! of TANKS <br /> P �, at SITE <br /> P 67 <br /> APPLICANT/BILLING RM APPLICANT CONTACT NAME <br /> C (MAILING ADDRESS APPLICANT PHONE 9 UITH AREA CODE <br /> T CITY STATEJ ZIP CODE TYPE of APPLICATION $rS�F3 u pts <br /> SUS�G <br /> c)51)-';z' (Closure, Installation, etc.) <br /> me r?-FiCp7ZCY1 <br /> TOTAL <br /> ( <br /> ANNUAL FACILITY REE (Prior to .taut' 1, 1949) = 3100.00 1906 1487 1985 1489 1990 <br /> C x= moo: XXXx x= =m S <br /> T FACILITY PENALTY FEES ASSESSED (If Appticabte) # xm xxxx XX%X XXXX x)DOI 5 <br /> I <br /> V TANK FEE : $50.00/TANK (Prior to January 1,1991) 3170/TANK (After January 1, 1941) <br /> E <br /> x Tanks a 1997 1988 1984 1990 1441 ! 1942 TM 1944 ! 1995 1946 1947 <br /> F (multipty Y by fee for <br /> A each year applicable) 10Ocx xxxx xxxx xxxx xxxx f 3 <br /> C <br /> I TANK PENALTY FEES A M 3 M XxxX I xxxx I xxxx x)IXX = ( f 5 <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY * $18.50 �S <br /> T <br /> Y x Tank; x 58.00 1988 thresh 1990 ($56) 1991 through 1996 CS56) 1997 <br /> SURCHARGE FOR 1447 XYXXx 3 <br /> CPERIaANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. 0(s) <br /> L <br /> 0 CLOSURE FEE - 378_00/hour (3 hours minimtea/TANK) N TANK(s) X S234.00 0 5 <br /> S <br /> U TEMPORARY CLOSURE (Plant Review 6 Inspections) TANK I.0. 0(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 378.001how (3 hours minim WFACILITY) S234.00 m#niman S <br /> P INSTALLATION PLAN CXECS: (Ptah Review 8 Constrt�tion Inspections} TAID( I.D. x(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/1hour (8 hours minimum/FACILITY) ■ Sl minimumt S <br /> R REPAIR FEE (Norkptan Review i Comtruetion Inspections) TAW I.D. 0(s) <br /> E <br /> P TANK LINING REPAIR FEE 9 S73.00/hour (3 hours iainimWTANK) 0 TANK(s) X _00 v S <br /> A <br /> I TANK RETROFIT REPAIR FEE s S78.00/hou- (3 hours min./FACILITY) = 3234.00 minjolum S <br /> R <br /> PIPING REPAIR FEE s $78.00/how- CS hal mintimUla/FACILITY) .00 Minimumf <br /> N TRANSFER PEE : $20.00 THORIZEO RELEASE EVALUATION = S78.00/hr S s1 <br /> I m� <br /> S <br /> C CONSULTATION FEE : 378.00/hr SAMPLING INSPECTION FEE z 378.00/hr } S <br /> TOTAL DUE f <br /> FOR OFFICE USE ONLY <br /> SLEEPS ffi 4 COMPUTER 9 LOC CODE GIST CODE AMOUNT RECEIVED { CNEdK #/CASH RECEIVED BY ' DATE RECEIVED -� <br /> s <br /> ;5 <br /> .l•.._ .4!t_l�.P:rili._.. ._.__........... <br /> ..... .. -'_s..ll <br /> :. <br /> ... ^mr:me.ara-...... ...._..-. �:«--meen:::. ..m�.—::::... - 9!t16 <br /> ._.-.......-:.......Gfuiu::°=:::._._. mss: �...........«.3fltlt. ..p' ... <br />