Laserfiche WebLink
SAN JOAQUIN C PUBLIC HEALTH SERVICES ENVIRONMENTAL HE DIVSION <br /> UNDEiIGROUND STORAGE TANK PR WORK <br /> FACILITY CONTACT NAME <br /> 1 FACILITY ?E NAME �� S--7lj _„ 9 /,� / �77.� <br /> T' -�J /Y y'�` SITE pPH$ME # With /A(RrEA CODE <br /> E FACILITY ADD/RES�Sy _n� -20 11rb7 —IMj <br /> K STATE ZIP CODE # of TANKS <br /> CITY� n //1 � � at SITE <br /> A r 1 ccc "�"'ttt <br /> P APPLICANT CONTA T NAME <br /> P APPLICANT/BILLING NAME / J f�,) S�UIwL �!/L%� �J <br /> I APPLICANT PHONE # WITH AREA CO E <br /> C MAILING ADDRESS �` J �3r i <br /> A ,� lv 7 Vim- `�-J ��'" <br /> NSTATE ZIP CODE TYPE of APPLICATION <br /> T C17Y �/ f' ,1 /'� � ( osur , Installation, etc.} <br /> rlj vCrTZJj�J `-Tr TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> xxxx xxxx xxxx XXXX xxxx ' $ XXxxxxxx <br /> A <br /> C xxxx xxxx xxxx xxxx xxxx $ XXxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable} <br /> I $170/TANK (After January 1, 1991) <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br /> E 1988 1989 1990 1991 1992 1993 1994 1945 199b 1997 1998 <br /> # Tanks = <br /> F (multiply # by fee for <br /> A each year applicable) xxxx xxxx xxxx xxxx xxxx <br /> C $ <br /> 1 TANK PENALTY FEES ASSESSED xxxx xxxx xxxx XXXX xxxx <br /> L $ <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY= 10-c%) <br /> T 1988 through 1943 ($56) 1993 through 1997 ($56), 1998 <br /> Y # Tanks x $8.00 ' <br /> SURCHARGE FOR 1998 xxxxxxxxxxxxxxxxxxxxxxxxxxx XXXXXXXXXxxXXXXXXXXXXXX <br /> C PERMANENT CLOSURE (Removal or Authorized Closure in Place) <br /> TANK I.D. #(s) <br /> L # TANK(s) <br /> X $234.00 - $ <br /> 0 CLOSURE FEE = `578.00/hour (3 hours minimum/TANK) <br /> S TANK I.D. #(S) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R $234.00 minimum $ /v I <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY} <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK 1.0. #(S) <br /> L <br /> A = $524.00 minimum <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) <br /> TANK I.D. #(s) <br /> E X $234.00 = S <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) <br /> A $ <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br /> R = $234.00 minimum $ <br /> PIPING REPAIR. FEE _ $78.00/flour (3 hours minimum/FACILITY) <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br /> I <br /> S = $78.00/hr $ <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE $ <br /> USE ONLY ::::::::•::•::::: <br /> OFFICE ..............................................::::::::::::::::::::::::::::::�:�:::::::::.::.:::s:::::::::s ::::•:::.::::::::::::::. __ °,::::::,;:;::::::::::: <br /> FOR ...,. ,:..,.... <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED 8Y DATE RECEIVED <br /> EH 23 032 (REVISED 1-12-98) <br />