Laserfiche WebLink
�- SAN JOAOI <br />FACILITY SITE NAME <br />T <br />E FA ILITY ADDRESS <br />� f <br />CITY <br />A �To <br />P AppLICANTA MLING NAME <br />L <br />1 <br />C MAILINGADDRESS <br />N �dr� <br />T �. <br />T CITY , <br />C HEALTH SERYICES - ENVIRONMENTAL HEALTH DIVSION <br />STORAGE TANK PROGRAM - FEE WORKSHEET <br />FACT TY CO TACT N <br />A� <br />,^ SITE PHONE # with AREA CODE <br />STATE ZIP CODE # of TANKS <br />r, A at SITE <br />GAPPLICANT CONTACT.,LME <br />01 <br />,AP pLjCANT PHONE # WITH ARE CODE <br />STATE ZIP COOS TYPE of APPLICATION <br />//-A (Closure, Installation, etc.) <br />FEE (Prior to January 1, 1991) = $100.00 <br />XXXX XXXX <br />s <br />ANNUAL FACILITY <br />A <br />XXXX I XXXX <br />C <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) <br />I 1,1991) S170/TANK (After January 1, 1991) <br />(Prior to January <br />V TANK FEE = s50.00/TANK <br />1992 1993 1994 1995 1996 <br />E 7 1988 1989 1990 199,I I <br />I I <br />_ 1986 198 <br /># Tanks - <br />I <br />S <br />F (multiply x by fee for I <br />XXXX XXXX <br />I I <br />A each year applicable) <br />I <br />s <br />C XXX <br />I TANK PENALTY FEES ASSESSED X XXXX I <br />I <br />L= SSb.00 each TANK (Due every 5 years) See California <br />H & S Code, Section Z5287 <br />I STATE SURCHARGE <br />1991 through 1996 <br />T 1988 through 1990 <br />Y # Tanks x 556.00 <br />s <br />(Enter amount and year) <br />CLOSURE (Removal or Authorized Closure -in-place) ITANK <br />I.D. #(s) <br />C PERMANENT <br />L <br />S78.00/hour (3 hours minimum/TANK) <br /># TANK(S) X S234.01[11 = <br />s <br />0 CLOSURE FEE = <br />TANK I.D. #(s) <br />S <br />U Inspections) <br />TEMPORARY CLOSURE (Alan Review & Inspe <br />$ <br />R <br />CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />E TEMPORARY <br />CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />P INSTALLATION PLAN <br />l <br />A <br />CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />= $624.00 minimum <br />S <br />N PLAN <br />FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />R REPAIR <br />E <br />P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br /># TANK(s) X S234.00 = <br />S <br />IBJ <br />S 2 `Lpa Q 6gL <br />A <br />RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= S234.00 minimus <br />v 7 <br />s <br />I TANK <br />R <br />FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= s234.00 minimae <br />PIPING REPAIR <br />578.00/hr <br />UNAUTHORIZED RELEASE EVALUATION = I I <br />s <br />M1 TRANSFER FEE = S20.00 I I <br />1 <br />I 1 <br />S I SAMPLING INSPECTION FEE <br />C CONSULTATION FEE = S78.00/hr <br />= 578.00/hr <br />DUE <br />S <br />5Eg <br />TOTAL <br />.31 <br />FOR OFFICE USE ONLY -Eli "- ' -�- I RECEIVED 3Y I GATE RECEIVED 3 <br />— —. RECEIVED CHECK ;*/CASH <br />SWEEPS # I COMPUTER # I LOC CODE I DIST CODE AMOUNT <br />3 <br />EH 23 032 (REVISED 10-28-93) <br />