COMPLIANCE INFO_1995-2004 - Laserfiche WebLink

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• SAN JOAQUIN I'Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL HI& DIVSION UNDERGXUMD STORAGE TANK PROGRAM - FEE WORKSHEET SI 11T FACILITY SITE NAME o I FACILITY CONTACT NAME 1986 1987 1988 1989 1990 E FACILITY ADDRESS SITE HONE # with AREA CODE # TANK(s) X 5234.00 = ry� TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) XXXX CITY STATE ZIP CODE # of TANKS � � Izem o \jW F SIC):L c� TANK I.D. #(s) at SITE PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) R P APPLICANT/BILLING NAME APPLICANT CONTACT NAM L� TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) �. I T C A MAILING ADDRESS /)-- C6 APP ICANT ONE # WITH AREA CODE �. S N T CITY STATE ZIP CODE TYKE of APPLI I V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 3170/TANK (After January 1, 1991) (ClosurInstalIa etc.) TOTAL PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) 1986 1987 1988 1989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 0 CLOSURE FEE = 378.00/hour (3 hours mini= WTANK) # TANK(s) X 5234.00 = f TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) XXXX XXXX S 3 p U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) R S C E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S I V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 3170/TANK (After January 1, 1991) E 4 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 F A (multiply # by fee for each year applicable) XXXX XXXX I $ C I TANK PENALTY FEES ASSESSED XXXX XXXX I S L 1 I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 T Y /� # Tanks'S x $56.00 15M through 1990 1991 through 1996 (Enter amount and year) C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) El TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 L A N 0 CLOSURE FEE = 378.00/hour (3 hours mini= WTANK) # TANK(s) X 5234.00 = f TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) R S E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ P INSTALLATION PLAN CHECK (Plan Review & instruction Inspections) TANK I.D. #(s) El TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 L A N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) El TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 A I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S R PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum S M TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr I � S C CONSULTATION FEE = $78.00/hr I SAMPLING INSPECTION FEE = 378.00/hr S 5 TOTAL DUE S FOR OFFICE USE ONLY � ------........�.:......_.. _.....__._.._..._— _... �........_................_ _ __ __.__......_......................................................._._....._...� __ . _ ............._._ _................._.... _ SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED 3 EH 23 032 (REVISED 10-28-93)