COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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SAN JOAQUIN CgW PUBLIC HEALTH SERVICES - ENVIROWIENTAL TH DIVSION .L46VMQM STORAGE TANK PROGRAM - FEE W1ORXSHEdW 5 I T FACILITY SITE NAME/ ^�L,� Q1?V /v L FACILITY CONTACT NAME 4,45W1 /"69 E FACILITY ADDRESS3& A/, �� f SITE PHONE.# with AREA CODE $ S # TANKCs) X $234.00 = A CITY �! STATE ZIP CODE # of TANKS E TEMPORARY CL RE FEE = 578.00/hour (3 hours minimum/FACILITY) I S234.00 minion [� �'�00 at SITE P 1988 1989 1990,- 990-ANNUAL P APPLICANT/BILLING NAME APPLICANT CONTACT NAME 1, 1991) = S100.00 MAILING ADDRESS C A�f APPLICANT PHONE # WITH AREA CODE �r - i T CITY STATE ZIP COOS . TYPE of APPLICATION 1416rAC4,4 ft1YU / Si2T (3 (Closure, Installation, etc.) C PERMANENT CLOSURE (Removal ofthorized Closure -in-place) TANK I.D. #(s) L E O CLOSURE FEE = $78.00/h (3 hours minimum/TANK) I # TANK(s) X 5234.00 = $ S # TANKCs) X $234.00 = S U TOTAL E TEMPORARY CL RE FEE = 578.00/hour (3 hours minimum/FACILITY) I S234.00 minion IFR S R 1986 1987 1988 1989 1990,- 990-ANNUAL ANNUALFACILITY FEE (Prior to January 1, 1991) = S100.00 XXXX XXXX XXXX XXXX S A C T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX S I V E TANK FEE = S50.00/TANK (Prior to January 1,1991). 5170/TANK (After January 1, 1991) # Tanks= 1986 1987 1988 ( 1989 1990 1991 1992 1993 1994 1995 1996 F (multiply # fee for XXXX XXXX XXXX XXXX SDS A each year applicable) C !�+ I L TANK PENALTY FEES ASSESSED XXXX XXXX XXXX I XXXX $,, I STATE SURCHARGE = 856.00 each TANK (Due every 5 years) See Catifornia N & S Code, Section 25287 T Y # Tanks x S56.00 1988 through 1990 1991 through 1996 (Enter amount and year) p C PERMANENT CLOSURE (Removal ofthorized Closure -in-place) TANK I.D. #(s) L E O CLOSURE FEE = $78.00/h (3 hours minimum/TANK) I # TANK(s) X 5234.00 = $ S # TANKCs) X $234.00 = S U TEMPORARY CLOSURE an Review & Inspections) TANK I.D. #(s) E TEMPORARY CL RE FEE = 578.00/hour (3 hours minimum/FACILITY) I S234.00 minion IFR S P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimumS ��e R REPAIR FEE (Workplan Review& onstruction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FE S78.00/hour (3 hours minimum/TANK) # TANKCs) X $234.00 = S A I TANK RETROFIT R IR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S R PIPING REP R FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S M TRANSFER FEE = S2 I S ..�. _ C CONSUL TAT IO EE = S78.00/hr FOR OFFICE USE ONLY -- _ - ........... ,- N SWkEPS #. COMPUTER # LOC CODE UNAUTHORIZED RELEASE EVALUATION = S78.00/hr SAMPLING INSPECTION FEE DIST CODE AMOUNT S = S78.00/hr S S TOTAL DUE S VED I CHECK #/CASH I RECEIVED BY 8 WA DATE RECEIVED