Laserfiche WebLink
A 4, ll. .. <br />SAN JOAQUINAaPUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION <br />STORAGE TANK PROGRAM - FEE WORKSHEET <br />SI <br />FACILITY SITE NAME <br />"� <br />FACILITY CONTACT NAME <br />Tc <br />L_ A <br />a_ r ,' <br />t <br />S <br />U <br />1986 1987 11988 <br />E <br />FACILITY A06RESS <br />l7oo c, ye'5 „� <br />SITE PHONE 0 with AREA CODE <br />9,!�) 9 - elm _ 74 7 (6 - <br />-CITY <br />A <br />CITY <br />STATE <br />ZIP CODE <br />I it of TANKS <br />at SITE <br />A <br />XXXX XXXX <br />P <br />P <br />APPLICANT/BILLING NAME - <br />AP LICANT CONTA NAME <br />XXXX I XXXX <br />( ( <br />C <br />MAILPG AOORESjS <br />APPLICANT PHONE V WITH AREA CODE <br />A <br />E <br />T <br />CITY <br />A, <br />STATE <br />e, <br />ZIP CODE <br />TYPE of APPIIS'•LTION <br />(CLosure Instalt_atian,- etc.) <br />To <br />C <br />PERMANENT CLOSURE (RemovaL or Authorized Ctosure-in-Place) I <br />TANK I.D. #(s) <br />L <br />0 <br />IWAL <br />TANK(s) X $234.00 = <br />t <br />S <br />U <br />1986 1987 11988 <br />1989 11990 <br />R <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />$ <br />A <br />XXXX XXXX <br />5 <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX I XXXX <br />( ( <br />3 <br />I <br />V <br />TANK FEE _ $50.00/TANK (Prior to January 1,1991) <br />3170/TANK (After January 1, 1991) <br />E <br /># Tanks = <br />1986 <br />1987 <br />1988 11989 11990 <br />1991 1992 11993 <br />1994 <br />1 1995 1996 <br />F <br />(multiply X by fee for <br />A <br />each year applicable) <br />XXXX <br />XXXX <br />S <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />I XXXX <br />XXXX <br />I <br />5 <br />L <br />I� <br />STATE SURCHARGE = 356.00 each TANK (Due every 5 years) <br />See California H & S Code, Section 25287 <br />T <br />Y <br />9 Tanks x 556.00 <br />1988 through 1990 <br />1991 through 1996 <br />(Enter amount and year) <br />S <br />To <br />C <br />PERMANENT CLOSURE (RemovaL or Authorized Ctosure-in-Place) I <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) <br />TANK(s) X $234.00 = <br />t <br />S <br />U <br />TEMPORARY CLOSURE (Alan Review & Inspections) <br />TANK I.O. N(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />$ <br />Pt INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. 9(s) <br />- <br />L <br />A <br />N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) I TANK(s) X 5234.00 = <br />S <br />A <br />I <br />= <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) 5234.00 minimum <br />$ °s <br />ct <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum <br />$ <br />MI TRANSFER FEE _ $20.00 <br />I <br />S <br />ClCONSULTATION FEE = 378.00/hr <br />FOR OFFICE USE ONLY <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />S <br />S <br />TOTAL DUE I S <br />EH 23 032 (REVISED 10-28-93) 3 <br />