Laserfiche WebLink
• SAN JOAQUIN CP PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEI DIVSION <br /> UN(]1sdtCUND STORAGE TANK PROGRAM - FEE WORKSHEET\- <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T F.004, <br /> E FACILITY ADDRESS SITE PHONE 0 with AREA CODE <br /> & ce - SH I - L3 <br /> CITY STATE ZIP CODE0 of TANKS <br /> A <br /> P 5� C R5 ZLt) at SITE I <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> N W, # ZO - <br /> T CITY STA//TttE ZIP CODE TYPE of APPLICATION <br /> C g5'J"10 (Closure, Installation, etc.) Clo -'l e- <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> A xxxx xxxx I xxxx )0= f <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) X)= xxxx xxxx I xxxx 5 <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # pLY bYby fee for <br /> 0 1986 11987 11988 1989 11990 1991 1992 11993 11994 11995 1996 <br /> F <br /> A each year applicable) xxxx xxxx I xxxx xxXx I f <br /> 1-70C <br /> I TANK PENALTY FEES ASSESSED I X100( xxxx I xxxx I xxxx I I I ! I f <br /> L <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & 5 Code, Section 25287 <br /> T <br /> Y 0 Tanks x (56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <br /> C� PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. 0(a) <br /> L <br /> 0 CLOSURE Fc = 578.00/hour (3 hours minim n/TANK) I 0 TANK(s)J_ X 5234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. 0(s) <br /> E) TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspection$)I TANK I.D. 0(s) <br /> L <br /> A <br /> X PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minimm 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. 0(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) 0 TANK(s) X 5234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours miniuLzn/FACILITY) = 5234.00 minimum S <br /> N TRANSFER FEE - $20.00Ij UNAUTHORIZED RELEASE EVALUATION = 578.00/hr s <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S 00 <br /> FOR OFFICE USE ONLY <br /> SWEEPS 0 I COMPUTER 0 LOC CODE DIST CODE I AMOUNT RECEIVED CXECK 0/CASH I RECEIVED BY DATE RECEIVED 3 <br /> a <br /> u, a u�^ lncvLSEO •.'G-Yi) <br />