Laserfiche WebLink
SAN JOAQUIN r '!TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL ' '.TH DIVSION <br /> RGROUND STORAGE TANK PROGRAM - FEE WORKSHE <br /> S FACILITY SIJE NAME FACILITY CONTACT NAME <br /> I S� ( ( <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> cZ <br /> CITY OE� ZIP_COOE # of TANKS - <br /> A S'. G at SITE <br /> PF <br /> P APPLIC!Nj/BILLING NAME APPLICANT CONTACT NAME <br /> L c <br /> IIL <br /> C MAILING ADDRESS APPLICANT PSNE WITH AREA CODE <br /> Nl '�/ ti Y,5 <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A S <br /> C1 <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX $ <br /> I <br /> VI TANK FEE _ $50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 4 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = $78.00/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 = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> PI INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /> R .REPAIR FEE (Workp(an Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ ; 0 O <br /> R ' . <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> M <br /> I TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr I SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE , S <br /> FOR OFFICE USE ONLY <br /> _.................._............_............._........--..�_._�.Y.—__.__.._ r___..._._._..._.._..._. <br /> ..............:........................ :s:-::a s:-`:=`'_ :��_ ......................... =i[ :`€= :-s: ::s:-:.. <br /> ........................... <br /> SWEEPS # I COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY I DATE RECEIVED <br /> La <br /> _...................._::._:.......:..... :._....._...:...__:: :::: z _. _............................._..__.....__..._...__ .��...::::::.:-- ....._:::- � ..� ._ <br /> _.. <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />