Laserfiche WebLink
a SAN JOAQUIN CLO PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE DIVSION <br />V UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAMEUl, <br />FACI�LpIT�Y/ CONTACT NAME <br />T <br />U 1�•� `�C, <br />�I®N V I�1T <br />L <br />0 <br />CLOSURE FEE _ $78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />& <br />e, N .Gbh (5— - LE c <br />_ $234.00 minim <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) <br />_ $234.00 minimum <br />R <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />P <br />C, <br />at SITE 3 <br />S <br />C <br />CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE <br />P <br />APP !CANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />1 <br />_Abt� <br />$ <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />5u- G 94LO s -T <br />2®'f • 583- SS3S-- <br />N <br />-Ie <br />T <br />CITY STATE ZIP CODE TYPE of APPLICATION <br />f�,KIF eQ , (Closure, Installation, etc.) G b� <br />TOTAL <br />1986 1987 1988 1989 .1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br />A $ <br />C <br />T FACILITY PENALTY FEES ASSESSED (if Applicable) XXXX XXXX - $ <br />I <br />V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK, '(After January 1, 199j) �. <br />E <br /># Tanks = 1966 1987 1988 1989 1990 1991 1992 1993 1994 1995 1946 <br />F (multiply # by fee for <br />A each year applicable) $ <br />C <br />I TANK PENALTY FEES ASSESSED xxxx xxxx f <br />L <br />I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />T <br />Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br />(Enter amount and year) <br />f <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) <br />1.0. #(s) <br />L <br />REPAIR FEE (Workptan Review & Construction Inspections) <br />L <br />0 <br />CLOSURE FEE _ $78.00/hour (3 hours minim/TANK) # TANK(s) X $234.00 <br />f <br />N <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimusVFACILITY) _ $624.00 minimus $ <br />A <br />I <br />S <br />_ $234.00 minim <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) <br />_ $234.00 minimum <br />R <br />E <br />I TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimun/FACtLtTY) _ $234.00 minimum <br />$ <br />P <br />INSTALLATION PLAN CHECK (Plan 'Review & Construction Inspections)TANK <br />1.0. #(s) <br />R <br />REPAIR FEE (Workptan Review & Construction Inspections) <br />L <br />A <br />TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) <br />N <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimusVFACILITY) _ $624.00 minimus $ <br />FOR OFFICE USE ONLY <br />................................... . <br />Tore w.. eeeees eeae waw mee »mese »» a <br />it <br />Ks mer ween wed woeee wme meoese>ae fine►»«» uo►eee <br />as ,vu re�mu � tit sr�a ta�rox aex � r to tau � <br />EH 23 032 (REVISED 3-1-93) <br />Paae 11 <br />..................... i.... .... ...... .... ...... .... .... .I .... .... .wz <br />eeewe xe►maw mus w>ew+s ui+> wms oee«e>mee emeses xa wee wooed wee wee <br />AM6 Tat lqi r�lm lbw �+ra asst a�at ase <br />R <br />REPAIR FEE (Workptan Review & Construction Inspections) <br />TANK I.O. #(a) <br />E <br />P <br />TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) <br /># TANK($) X $234.00 a <br />; <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) <br />_ $234.00 minim <br />$ <br />R <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) <br />_ $234.00 minimum <br />$ <br />M <br />TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE. EVALUATION. _ $78.00/hr <br />$ <br />i <br />S <br />C <br />CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE <br />= S78.00/hr <br />$ <br />TOTAL DUE <br />$ <br />FOR OFFICE USE ONLY <br />................................... . <br />Tore w.. eeeees eeae waw mee »mese »» a <br />it <br />Ks mer ween wed woeee wme meoese>ae fine►»«» uo►eee <br />as ,vu re�mu � tit sr�a ta�rox aex � r to tau � <br />EH 23 032 (REVISED 3-1-93) <br />Paae 11 <br />..................... i.... .... ...... .... ...... .... .... .I .... .... .wz <br />eeewe xe►maw mus w>ew+s ui+> wms oee«e>mee emeses xa wee wooed wee wee <br />AM6 Tat lqi r�lm lbw �+ra asst a�at ase <br />