Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES • ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> 7 CITY STATE ZIP CODE I TYPE of APPLICATION <br /> (Closure, Instatlation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> A XXXX XXXX XXXX XXXX XXXX S xxxxxxxXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX S XXXXXXXXXxxxx <br /> I <br /> V TANK FEE = S5O.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (muttipty # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX 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 S56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> 5 8, <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour.(3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK E.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK E.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minimus S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimus/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I <br /> S ' <br /> -C CONSULTATION FEE = S78.00/hr SAMPLING-INSPECTION.EEE _ 578.00/hr <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY <br /> SWEEPS # COMPUTER # LOC CODE DIST.CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY OATSCEI <br /> REVED:;t <br /> m � - <br /> 9 <br />