Laserfiche WebLink
SAN JOAWIN COUNTIC HEALTH SERVICES - ENVIRONMENTAL NEALIIQN <br /> UNDER STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SFACILITY SITE NAME FACILITY CONTACT NAME <br /> IE E <br /> T `J <br /> 'E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & L� P <br /> CITY STATE ZIP CODE # of TANKS <br /> A � G at SITE <br /> P <br /> P APPLICANT/BILLING NAME /U APPLICANT CONTAQT NAME <br /> I (-V w <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA qCOE <br /> A <br /> TI CITY STATE ZIP CODE TYPE of APPLICATION ?' <br /> (Closure, Installation, etc.) <br /> 4 TOTAL <br /> 1986 1987 ` 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX XXXX XXXX XXXX 5 XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Appticabte) XXXX XXXX xxxx xXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) JA)U O 3 7a <br /> E <br /> 9 Tanks = 1988 1989 1990 1991 1992 199p• 1994 19f59 1 1996 1 1997 1998 <br /> F (multiply # y fee for <br /> Aeach year applicable) xxxx XXXX XXXX XXXX XXXX 1 7D 1 76 / 76 1 70 -LI© S IDAD <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX I , 1� 1-7 1-7011-10 I 3 <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T <br /> Y # Tanks x $8.00 1988 through 1993 ($56) 1993 through 1997 (356) 1998 g, Q(' <br /> SURCHARGE FOR 1998 XXxxxxxxxXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 378.00/hour (3 hours minim/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 = 578.00/hour (3 hours minimum/FACILITY) 3234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minim/FACILITY) = S624.00 minim S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) ( TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minim S <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I 1 <br /> S l <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY ---- „- - <br /> ..e..........r:::rr. :r».rxr.::• _ r.:rix....._..........._.....:raar «—s--�::::. :.:^=.�-.- •:.—_—:e::-_:.'=•m:a-cam ::.—: c.—.........«.............e»:::....._. <br /> .........t.............._..............3?tt:.."E...................-........_...«-.......-...............«....«............«..._.—.__......._-._._........._......«_._...... <br /> .._........._:...„r..........._..m.:s.-WE...e..ux:813..m. _.._.««:..s...•s.„»...a.s_«.__—....«.«._......M................--.._..,ze:= ;=__aca: :::.:: s:rr..:..r- .=::•s :•r�:a:i5ui:c_::ic:e�_.-...__:•c:. .. <br /> SWEEPS # COMPUTER # LOC CODE GIST CODE AMOUNT RECEIVED i CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> i1 <br /> ;= s <br /> .. ::...........,...H........................�... .............-.......—.. ............._..........__.............. ._......._-.........._ _ - <br /> _.._.. .........._.... _................_... _.._...._..._._._.. _...._.._:::: :::::::-w:::::_..._..- <br /> ..:....:1...........................„.:.......................E1-8i8_............. ... ................-...-.:........_. ..................._.::....:.._::�..........._ ......... .. <br /> iE <br /> KMPe <br /> .; 3 s - <br /> r <br /> • `, raj <br /> C � ( <br /> ' / <br />