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C <br />4. <br />SAN JOAQUIN g&TY PUBLIC HEALTH SERVICES - ENV% NTALTH DIVSION <br />TANK I.D. #(s)� "�y <br />GROUND STORAGE TANK PR - FEE N <br />b_S <br />S <br />FACILITY SITNAME <br />E <br />FACILITY CONTACT NAME <br />I <br />^v-p�- <br />�.�-�--1 ( �( �� C E� S <br />I <br />'�T �� E :5—n / <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION <br />T <br />I <br />R <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />E <br />FACILITY ADDRESS <br />= 578.00/hr 5 <br />SITE PHONE # with AREA CODE <br />l -? I�(ncoc.-1 2(D <br />-0_0,-7 -1?-5r- r -�o <br />& <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />AI" <br />DC K -7 -OA( <br />!SZi S <br />at SITE <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />re.1 rJ I -re l:) <br />I <br />C <br />MAILING ADDRESS i� <br />APPLICANT PHONE # WITH AREA CODE <br />-5-3q4 <br />—2=5- <br />A <br />Z6GiCi �. ZSTff "7 J� <br />Ja�Io Z ?0(- <br />N <br />T <br />CITY STATE <br />ZIP CODE TYPE of APPLICATION V PE+2rn De <br />S (G /vim F It L( CA <br />Sp$O(., (Closure, installation, etc.) <br />TOTAL <br />1986 <br />1987 11988 1989 <br />1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = s100.00 <br />A <br />XXXX <br />( XXXX i XXXX XXXX <br />XXXX s XXXXXXXX <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX <br />XXXX I XXXX XXXX <br />( XXXX 5 XXXXXXXX <br />I <br />V <br />TANK FEE = S50.00/TANK (Prior to January 1,1991) <br />I <br />5170/TANK (After January 1, 1991) <br />E <br /># Tanks = <br />1987 1988 <br />1989 1990 <br />1991 <br />11992 11993 11994 11995 1996 1997 <br />F <br />(multiply # by fee for <br />A <br />each year applicable) <br />XXXX XXXX <br />XXXX XXXX <br />(XXXX <br />I I 5 <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX I XXXX <br />I XXXX I XXXX <br />(XXXX I I I ( 5 <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 <br />95 <br />T <br />Y <br /># Tanks x 58.00 ( 1988 through 1990 ($56) 1991 through 1996 (556) <br />1997 <br />5 <br />SURCHARGE FOR 1997 XXXXXXXXXXXX%XXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s)� "�y <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 3234.00 = 5 <br />I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = <br />5234.00 minimum 5 <br />S <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION <br />= 578.00/hr s <br />I <br />R <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />I 5234.00 minimum 5 <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum 5 <br />2 <br />R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />E <br />P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # <br />TANK(s) X 5234.00 = 5 <br />A <br />I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = <br />5234.00 minimum 5 <br />R <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = <br />5234.00 minimum 5 <br />N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION <br />= 578.00/hr s <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br />= 578.00/hr 5 <br />FOR OFFICE USE ONLY <br />_.«iil•.i.::«::....'«"'L!:OS]«^..T.:«i«.••::::ii«...«...... ...«. ........ <br />: <br />:«'.«:::::i«1.i«�.::^_^':;_..�.':t.'.«E:«iei":..«::.�«•':.«..'.«.::::«.:...:...._._�_:.^.::«:«..�"...::::::.: <br />:..i::L.«LSF.'.:.""..�«::::�::::L;Y.':.'::�:«:.r:::..�•'•..:«". �:.^.«�:�.�..:i 53:.::"^«'J <br />SWEEPS # COMPUTER # I LOC CODE_I DIST CODE AMOUNT RECEIVED I CHECK #/CASH <br />...1»._._«. <br />............ <br />EH 23 032 (REVISED 5-27-97)/ <br />TOTAL DUE 15 <br />RECEIVED BY I DATE RECEIVED <br />