Laserfiche WebLink
SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAjjbPIVSIOM <br /> UN ROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME ! FACILITY CONTACT NAME <br /> I <br /> '"E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY STATE ZIP CODE # of TANKS <br /> A w at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> TI <br /> CITY <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX I XXXX XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXXXXXX XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1990 1991 1992 ( 1993 1994 11995 1996 1997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX I S <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXX XXXX I XXXX XXXX XXXX I I I I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 S <br /> T <br /> Y) # Tanks x S8.00 1988 through 1993 (S56) 1993 through 1997 (S56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C` PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) TANK I.O. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I # TANK(s) X S234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I S234.00 minimum S <br /> PI INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> NJ PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) ( # TANK(s) X S234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> A <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> Y <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> €€€€€ €............................ .M ..........- — :- • .....:...........................:..:::::.. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK */CASH RECEIVED BY i DATE RECEIVED . <br /> S I <br /> :a ......._......_.............__........._................_._ _ ...._._ �_......__ _.. __._..L.. ...__......._.._..._..__.__.. <br /> EH 23 032 (REVISED 1-12-98) <br />