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i <br />SAN JOACUIN 9W PUGLIC HEALTH SERVICES - ecvtRCWeXTAL 112kH DIVSIGM <br />QCUNO STORAGE TANK PROGZAX • Fz-- UCRXSNSiW <br />S� <br />FAC:LITY SITE NAME <br />1486 <br />� 1987 � <br />I fAC:L(TY CC1eTACT NAME <br />I <br />J' L L fl S <br />7/ c�rJ <br />F C<L i9lt S <br />r <br />'_( <br />FACILITY AOORESS <br />A <br />TANK RETROFIT REPAIR PEE = 37$_00/hour (3 hours min./FACILITY) <br />XXXX <br />I SITE PHONE ori U1 AREA CAME <br />`j <br />' o G o s <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />I XXX)( I xXXX I <br />xXXX I XXXX I XXXX s XXXXXXXX <br />/_-) O/Li <br />TANK FE. = 550.00/TANK (Prior cc January 1,1991) <br />CITY <br />E <br />ATE <br />ZIP CSE <br />A ct TANKS <br />A <br />t <br />(muttipty t by fee for <br />each year applicaate) <br />xW XXXX I XXXX I xXXX iXXXX <br />ac SITE <br />C� <br />I <br />/ <br />I XXXX X0= I XXXX xnx jXXXX I <br />I I <br />I ! I s <br />L' <br />I <br />P <br />P <br />APPLICANT/BILLING NAME <br />P <br />Y <br />" ranks X x3.00 <br />APPLICANT, CCINTACC NAME <br />L <br />e/?P ® I,LLL <br />SURCHARGE FOR 1948 <br />I XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />4A ff /'l1 <br />OS <br />C <br />RAILING AOORESS <br />C� <br />APPLICANT PHONE : WITH AREA CCAE <br />A <br />Z4y0 LG�/q�l <br />CLOSURE Fc. = s78.00/hour (3 hours minimum/TANK) I <br />4 TANK(S)_.,_S X <br />Io)6/ -83 ® (,x /v <br />S <br />U1 <br />Nj,1 <br />,5 <br />R <br />E <br />rEMPORARY CLOSURE FEE = s78.00/hour (3 hours minimua/FACILSTY) I <br />)d <br />T <br />CITY <br />S <br />STATE <br />ZIP CCOE _ • APPU CAT1GN <br />SAN DAQ <br />PI <br />G/Ll <br />91�� �� (Ctasure (rssta(cation, ecc.) <br />TOTAL <br />R <br />REPAIR FEE (Workptan Review L Construction (nspections) I <br />1486 <br />� 1987 � <br />1488 � 1989 17990 <br />TANK :WING REPAIR FE; = 378.00/how <3 hours minimLWTANK) I <br />ANNUAL FACILITY FE_ (Prior to January 1, 1991) = 5100,QQ <br />3 <br />A <br />TANK RETROFIT REPAIR PEE = 37$_00/hour (3 hours min./FACILITY) <br />XXXX <br />XXXX <br />XXXX XXXX I XXXk S XXXXXXXX <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />I XXX)( I xXXX I <br />xXXX I XXXX I XXXX s XXXXXXXX <br />V <br />TANK FE. = 550.00/TANK (Prior cc January 1,1991) <br />st%0/TRNK (After :anuary 7, 7`941) <br />E <br />3 Tanks 7 <br />j( <br />1488 t984 1990 1491 1492 <br />I ( I I <br />1943 144` 1995 <br />I <br />1996 1997 1448 j <br />f I <br />FI <br />A <br />(muttipty t by fee for <br />each year applicaate) <br />xW XXXX I XXXX I xXXX iXXXX <br />C� <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX X0= I XXXX xnx jXXXX I <br />I I <br />I ! I s <br />L' <br />I <br />STATE SURCHARGE FOR NEIJ FACILITIES ONLY --$18.7Q <br />P <br />Y <br />" ranks X x3.00 <br />1988 tArcugb 1993 (s56) <br />(493 :hrcugn 1547 <br />t556)� 1998 <br />SURCHARGE FOR 1948 <br />I XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />%XXXXXXXXXXXXXXXXXXXXXX I S <br />C� <br />PERMANENT C%CSURE (Removal or Authorized Closure-in-Ptacs) <br />TANK I.O. e(s) <br />0 <br />CLOSURE Fc. = s78.00/hour (3 hours minimum/TANK) I <br />4 TANK(S)_.,_S X <br />52"14.00 = S <br />S <br />U1 <br />TEMPORARY CLOSURE (Plan Review A inspections) I <br />rANK I.O. N(s( <br />R <br />E <br />rEMPORARY CLOSURE FEE = s78.00/hour (3 hours minimua/FACILSTY) I <br />3734,00 minimum <br />S <br />PI <br />INSTALLATION PLAN CHECX (Ptan Review 3 Cartstruc:ion Inspections)I <br />TANK I.O. +(s) <br />L <br />AlN <br />PIAN CHECK FE_ = S7$.QO/hour (8 hours miniftW FACILITY) <br />= S624.00 minimum <br />5 <br />R <br />REPAIR FEE (Workptan Review L Construction (nspections) I <br />TANK [.0. t(s) <br />E <br />P <br />TANK :WING REPAIR FE; = 378.00/how <3 hours minimLWTANK) I <br />t TANK(s) X 3234.Q0 a <br />3 <br />A <br />I <br />TANK RETROFIT REPAIR PEE = 37$_00/hour (3 hours min./FACILITY) <br />= 5734.00 minimcm S <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours- miniMM/FACILITY) <br />j <br />= S234.00 minims i S <br />Nf TRANSFER FEE = s20.OQ <br />11 <br />a-- <br />C1 CONSULTATION FEE = 578.00/hr <br />VAUTHORIZ0 RELEASE EVALUATION = 378.00/hr I I 5 <br />� 1 <br />SAMPLING (NSPECTICN FEE n S78.Q0/Rr I I f�3 <br />TOTAL. WE l S <br />FOR OFFICE USE ONLY <br />s <br />SWEEPS 9 ^I COMPurpu a LOG CODE atST CME AKUNT RECEEIVED CHECK N/CASH REC21VEO 3T l DATE RHG=IYE1) <br />3 ! I Is I l ! <br />:H 23 032 (REVISED 1-12-98) <br />VT 39tid a00 -1d H1dId EEV689V60Z TO:60 0002/GT/S0 <br />