Laserfiche WebLink
SAN JOAOUIN Cap PUBLIC HEALTH SERVICES- ENVIRONMENTAL HEMAR DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT AAME <br /> CtT <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> —1 J96100 <br /> CITY STATE zl� E # of TANKS <br /> A <br /> at SITE <br /> P <br /> P APPLICANT/BILLING N APPLICANT CONTACT, NAME <br /> L fC <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <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 XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) XXXX XXXX Xxxx XXXX XXXX $ XXXXXXXX <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX '1 $ <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 $ <br /> T <br /> Y # Tanks x $8.00 1988 through 1993 ($56) 1993 through 1997 ($56) 1998- <br /> SURCHARGE <br /> 998SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ <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/FACILITY) $234:00 minimum $ <br /> P 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 (Workplan 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 $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ <br /> TOTAL DUE $ <br /> FOR OFFICE USE ONLY - <br /> ............................................._......._........._............._....»...............;.............................................».................::t:::.............. ............:::::t::::: <br /> _.......... .. .. ............:.:...... .............»._......................_....................._:...».._..............................:................................................... <br /> ......................................... .......:.:::s..ttt.n.:ntt.........s..............r,........................t.......t. t.......... .................................................................................................................................... <br /> ...s..........:..........:........................t.......ss............ ...........................................................................................r............»...».... ........... .. .._..................................................................................................................... <br /> :............................................... ................................:..s...t....t..:s:...............:...t.:..::......._................s.::::r:::{:5.......................».........._.....s•::...t........�:::::::::.........:. ... ...........t.........................._.............................r::::i <br /> €t <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> i{E <br /> :_. <br /> aE $ <br /> ...............»._. . .....................::::••t::::•:::::::t:::::::::::::::. .:................................... <br /> ............................. ........:.:...:t.......t..t..:...... .t.t..............r.......:.:.s....n..........».»..........:.s.....t...:... :•. ..............{.......... <br /> ....:t.:..s....t....... .....................K.........?E..E.s...... ..:i... ...... ............................................................................ <br /> ..........t..E........................t.....t. ....................................................................»»................ ........................................................................................................ <br /> i...E..te................... .....»...........................».»... •...... s:.....................................:.:...........................................................::::: <br /> ......................................................................... ......................t.»...:........ .:....t.....................................s..t................:............................................... .... :....................................:....:......................t.......... <br /> ...............s............... :..r.................................s.......i.....t.......................t........»........................................ .........:............................. <br /> EH 23 032 (REVISED 1-12-98) <br />