COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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SAN JOAOUIN NTY PUBLIC HEALTH SERVICES - ENVIRORMENTALLTH DIVISION UjWGROUND STORAGE TANK PROGRAM - FEE WORKSHE S FACILITY SITE NAME G�p, FACILITY CONTACT NAME n-,, E FACILITY ADDRESS SITE PHONE # with AREA CODE PAYMENT & 4+CO W�.� I 201- 9!?) - 2) b& CITY STATE ZIP CODE # of TANKS A ��F-�N 0S215 at SITE 2 OCT 141997 P P APPLICANT/BILLING NAME Q APPLICANT CONTACT NAME L C N r��T$ (ZtGHA P-P G#,( v qp� JOAQUIN COUNTY I HON # WITH Ajy I%yyENTAL HEALTH bIVISION WMAlmi C MAILING ADDRESS APPLICANT PHONE A C000t 970 LQ AJ(4042 CAI Y0AJ 9P' 5f- 1?2+2 -9,500 N T I CITY _ STATE ZIP CODE TYPE of APPLICATION INWAU4TION Closure Installation etc.) SaN • anv CA q�h9s ( , R 4 TOTAL 1986 1987 1988 1989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = 3100.00 A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX C T FACILITY PENALTY FEES ASSESSED (If App(icable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXXXXXXX I V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 5170/TANK After January 1, 1991) E # Tanks 12, 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 I r F (multiply # by fee for A each year applicable) XXXX XXXX XXXX XXXX XXXX 40 $ 41i C Ii TANK PENALTY FEES ASS'SSE0 f XXXX XXXX XXXX XXXX XXXX $ L� �pc7 I STATE SURCHARGE _ $ 00 each TANK (Due everyyears) See California H & S Code, Section 25287 T Y # Tanks I- x UK.00 1988 through 1990 (Enter amount and year) Ci PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. 4(s) L 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum -1 - P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum -i<'-S $ 3(a R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ RI PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum X S�� ! $ 3 5) M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ I S C CONSULTATION FEE = 378.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ I / „ TOTAL DUE 3 d 4 FOR OFFICE USE ONLY ».. ................» « _ __,,_—-=--L.——.--�• :--::-_:::, ::--::::. _ i--_-...«.:»n:--=L ... -:..—--i::-:.--_— ::L--w.—. :..-- ::- ::i::::::.............::::....«.._....»». ......_ _...._....«»«..........._........».»..«. ..._..................--=s. -tet=-- _ ....«........_....«........ ......�.....«.. _«_... _.._... _«....«....._....._..««.__...«..«.__._...«.........».........._. _.__...»........._..__.......................... ::::_: ::::::::::::::::::::::::::••_ = : ...:_::__..._.._.... :•=::•a::.__ :� .... .:: ••� =_..«..««.... _ :M :w•«_ :••�M� .»_ SWEEPS # COMPUTER # LOC CODE , DIST CODE AMOUNT RECEIVED I CHECK #/CASH I RECEIVED BY DATE RECEIVED Y :z $ ..................«............................................ _._..........._._ « ..__.... ._ .............._...__......... ._...._......._...._.._ .__. _ »«.._».. ._» :: ........:............................... ..................................................... �•:::••::r.:r.•::s::r.::c:r.::::r..»........__.:::�::� 've izii«s:=r.«� :iia: �..a.:.-az'rf�.�:es:::::s.•::::::�...:::: ......................................................... ........»._�.......SY.�tt::•...:»�.....».... ..._«.«.........._««....«.»:....��_.«..._.._.L._«_.._«.C.....«_..........«�_.».�5....^.S:C:C.3f�:..i._._.L.«._..»..w...+. ': ..[:L..S '� ?t If s