|
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION
<br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET
<br /> S FACILITY SITE NAME FACILITY CONTACT NAME
<br /> T
<br /> E FACILITY ADDRESS - SITE PHONE # with AREA CODE
<br /> r1Lcc . ,.. S-/ -? - 9Yf -(o i3S
<br /> 8
<br /> CITY )) STATE ZIP CODE # of TANKS
<br /> A "L" c_/c FL''z (.vf :i-% 2 at SITE
<br /> P
<br /> P APPLICANT/BILLING NAME APPLICANT CONTACT N E
<br /> 1
<br /> C MAILING ADDRESS APPLICANT PHONE # W TN A EA CODE
<br /> N
<br /> T CITY STATE ZIP CODE TYPE of APPLICATION R CCC
<br /> "w cI/e hir_ C'4 CJ's Zo i (Closure, Installation, et ) Pa-a..b7
<br /> TOTAL
<br /> 1986 1987 1988 1989 1990
<br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00
<br /> A DO 1'/001 '-00 5 OU
<br /> C
<br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX O OU 1100 S O U
<br /> I
<br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991)
<br /> E
<br /> 0 Tanks = .2 1986 1 1987 1988 1989 1 1990 1991 1992 1993 1994 1995 1996 -
<br /> LITANK
<br /> ltiply # by fee for T
<br /> u
<br /> h year applicable) /00 /O 0 Y
<br /> PENALTY FEES ASSESSED XXXX XXXX /v � /00 l70TE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287
<br /> anks�x 556.001986 through 19901991 through 1996
<br /> ter amount and year) 1
<br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s)
<br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00
<br /> S
<br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) _.
<br /> R
<br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 = 5
<br /> P[PLA!C!ECK
<br /> LION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s)
<br /> L
<br /> A
<br /> N FEE = S78.00/hour (8 hours minimum/FACILITY) 5624.00 minium S
<br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s)
<br /> E
<br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 S
<br /> A
<br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S
<br /> R /.
<br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = 2234.00 minimus S L
<br /> VU LI {
<br /> M TRANSFER FEE 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr 5 L,
<br /> U
<br /> 1
<br /> S
<br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr ,
<br /> TOTAL DUE S �•a (�U
<br /> FOR OFFICE USE ONLY
<br /> ............................_....._.. __._.........:.:.. ... .....::::nm..._.._.................. n...m_..__ .....ii'!ni:
<br /> ................................... ........_._.. ___....... _ ::.»;..::::.... ...:.: a ... ...._ _,.,:.:d:v!m:uw..m.....:....::::d.n::.::::......,.�m:.,tui!.=.rt:T:!!!!_Ta!n,:,,a,.v,.suds,:,anrmu.aa:=.. RECEIVE!c�;m: :::!:j!
<br /> ::�,:::,:::::n:::.,:,a,a:: E:,::,!,,::,,,,:,! =nnn,,,:m!dr..un,.,:....n,!!,n,,,;;;,,,,,,,;,,_,..,,r'.n,.n:.n,..,,:.,,:..,�..,..:..,:...._a::
<br /> SWE@FS'# C PUTEk # LOC CODE GIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED 8Y DATE RECEIVED
<br /> 5
<br /> 3Z s
<br /> v 3 - -
<br /> _! !ii
<br /> EN 23 032 (REVISED 11-1-92) Page 11
<br />
|