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SAN JOAQUIN CMLVTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> GROUND STORAGE TANK PROGRAM - FEE WRKSH <br /> S1 FACILITY SITE NAME FACILITY CONTACT NAME <br /> T <br /> 7-WO G-U S OBJ zo <br /> E) FACILITY ADDRESS SITE PHONE i with AREA CODE <br /> + 7 E . ,L. a7'1� r0 R® a-of, oq - <br /> CITY / STATE ZIP CODE 9 of TANKS / <br /> OL (n O C/ �J�0 at SITE k <br /> PAPPLICANTS/-BILLING NAME —yam —}-� ` APPLICANT CONTACT NAME <br /> L / CO Y1 ! Y� a- / O YDS -Ty1 C , ( �0.. G lk C O G I <br /> C MAILING ADDRESS! - ( APPLICANT PHONE � WITH AREA CODE <br /> AlJ� V, IV .,_ I Aon G� / - G 338 <br /> T I CITY / --��' I STATEI ZIP CODE TYPE of APPLICATION <br /> I S TO G !'G. l C- 7l. �C�-- 9�r�, (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 ( 1987 C 19881989 ( i990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A ! <br /> C XXXX I XXXX ( XXXX I XXXX I XXXX 5 XXXXXXXX <br /> Tj FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX I XXXX I XXXX XXXX S XXXXXXXX <br /> I <br /> VI TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E; <br /> 1 Tanks = 1 1987 1988 1989 1990 11991 1992 i 1993 1994 1995 1996 i 1997 <br /> FI (multioly T by fee for <br /> Al each year apoticable) XXXX I XXXX I XXXX , XXXX lxxxxS <br /> C. i <br /> II TANK PENALTY FEES ASSESSEDI XXXX XXXX XXXX XXXX IXXXX S <br /> L; <br /> Il STATE SURCHARGE FOR NEW FACILITIES ONLY = S18.50 is <br /> Ti <br /> Y; T Tanks x 58.00 1988 through 1990 (556) 1991 through 1996 (556) 1997 <br /> i <br /> SURCHARGE FOR 1997 I XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C; PERMANENT CLOSURE (Removat or Authorized CLosure-in-Place) I TANK I.D. :(s) <br /> L: <br /> 01 CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) t TANK(s) X 5234.00 = S <br /> S' <br /> U) TEMPORARY CLOSURE (Plan Review & Insoections) TANK I.D. ;*(s) <br /> R <br /> El TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) ( S234.00 minimum S <br /> `l� INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. T(s) <br /> NI PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. 5(s) <br /> E <br /> P1 TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I TANK(s) X 5234.00 = S <br /> A <br /> I1 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) ONE = 5234.00 minimum ' S '2 3±2 0 O <br /> NI TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I i S <br /> C! CONSULTATION FEE = S78.00/hr ! ! SAMPLING INSPECTION FEE = S78.00/hr ! S <br /> TOTAL DUE S /J 3.1% 00 <br /> FOR OFFICE USE ONLY <br /> - � <br /> SWEEPS ICOMPUTER I LOC CODE DIST CODE AMOUNT RECEIVED ( CHECK */CASH RECEIVED BY �� DATERECEIVED_ <br /> EH 23 032 (REVISED 5-27-97) <br />