COMPLIANCE INFO 1988 - 2002 - Laserfiche WebLink

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SAN JOAQU'COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENVEALTH DIVISION ERGROUND STORAGE TANK PROGRAM - FEE WORKS S FACILIT SITE NAME FACILITY CONTACT NAME I T E FACILITY ADDRESS SITE PHONE # with AREA CODE & CITY STATE ZIP CODE # of TANKS Pr n G��'� at SITE 3 P APPLICANT/BILLING NAME �-�1 APPLICANT CONTACT NAME LLt�oA S I C MAILING ADDRESS APPLICANT PHONE # WITVIREA CODE A 925 -2-71 (v T CITY STATE ZIP CODE TYPE of APPLICATION q ( (Closure, Installation, etc.)� ICA TOTAL 1986 198j1989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 A X%XX !]] %XXX XXXX $ XXXXX XX%%x% C T FACILITY PENALTY FEES ASSESSED (If Applicable) %XXX %XXX XXX% $/XXX%XXXX%XX%X I V TANK FEE = $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) E # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 F (multiply # by fee for A each year applicable) XXX% XXXX %XXX XXXX XXXX $ C 1 TANK PENALTY FEES ASSESSED XXXX XXXX %XXX XXXX XXXX $ L I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 T Y # Tanks x $56.00 1 1988 through 1990 1991 through 1996 (Enter amount and year) C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) L 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s)_ X $234.00 $ S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum ,E P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ -- A I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ R PIPING REPAIR FEE $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ 2a�f/L� M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ 1 S C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ TOTAL DUE $ 234. f FOR OFFICE USE ONLY .... .........._... -:::::::iiia"ttttttt!r�,..;. ....................... ........ _... .. .... _.....:...:.................................................::::::: ::::... ... ::::.., :_:!::.:a:::.:::............... ......................... ......... ........ .........::... . ..:�.::::.::.........:.......... .... ... ........._.... ............. . .. :................:,::: ......................... .....................................:..... ....................... _.... ................ ..... ............ ....... . .......... ............ii!i,:::i :: .....:::::!!i!i!_!::i!__a!!�_iii!_!!!!!��_.:!!!!__a:::::i!i isisi:!�::-::::siiii:i;a:iiii:i!::�:::::;iii;:::::::::�:::: iiii:<:;ai:iiiiiiiiiiiii!i!!!!!! SWEEPS # COMPUTER # I LOC CODE I DIST CODE AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY DATE RECEIVED ' li! �i ..................................................._.........................o.........................__..........................._.........._.::H....................................................._........._...__........._.._ _ .. .— ::::::-.:�:: m .................:.............................._.............._._................_......................._..........................:::::: : :::::::::::::::::::::::::::::::::::::::::::::::::_:::::::::::::: aiiiii !!!aa-�i!i:!:! a:=_=:!!!..............::::::::::::::;_!:::!:!!- =.iiiiiii�__!!!ii .::::::::::::.::::............___.____:a: iaii^v'ii!4!6�iiiiiii�w'r!iF_ieliiiiLiiiiii5lii!iiiii'e"�i_!i!!i!" �_i6_!!__3!!!!!i'iiiF3Tv!.. ::::ii!i!!!ii!i—�!!!!!!ii!=!i!!iiii!