Laserfiche WebLink
SAN JOAQUIN C 7 PUBLIC HEALTH SERVICES - ENVIRONMENTAL P 'N DIVSION <br /> U, .GROUND STORAGE TANK PROGRAM - FEE WORKSHEL <br /> T FA3�Y ITE NA�(E ' FA CITY CONTACT/NAME <br /> he Nen <br /> 3 FACIILITY DREG. Cih C��2r �� SITE PHONE # with AREA CODE <br /> L�' 09M <br /> CITY W v STATE ZIP CODE # of TANKS <br /> A StCK� CA 950 Tat � - �ernatin/ <br /> P <br /> 22 <br /> P APP CANT/BILLING NAM APPLICANT CONTACT NAME <br /> Kon thea n n1 � <br /> C MAIL G ADDREPPL(CANT PHONE # WITH AREA CODE <br /> M Ac)( Zq3 <br /> T CITY STATE ryZIP CODE TYPE of APPLICATION aACk- <br /> l o n ( —!5 � (Closure, Installation, etc.) FjES <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ &100.00 <br /> A X)O(X XXXX 100 /00 /00 s �O <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX j 100 1 /Qp /oo f 3 QO <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> E <br /> At Tanks = 1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for I <br /> A each year applicable) XXXX XXXX 50 50 SU1� I�0 S O <br /> C <br /> I1 1 <br /> TANK PENALTY FEES ASSESSED XXXX XXXX 50 SD 50 I�-0 �� 1�0 $ �o O <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x &56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) I r// // <br /> 5c0 Sip <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours mininuNTANK) # TANK(s) X $234.00 = f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspectiorre) TANK I.O. #(s)_ <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimlm/TANK) # TANK(s)_ X (234.00 = f <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minima /FACILITY) _ $624.00 minim m f <br /> RI REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> Al TANK LINING REPAIR FEE = $78.00/hour (3 hours mininaxn/TANK) I # TANK(s) X SZ34.00 = f <br /> II TANK RETROFIT REPAIR FEE - $78.00/hour (3 hours min./FACILITY) - $234.00 minimw S <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = S234.00 minima f <br /> I4 TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr f <br /> I <br /> 5 <br /> C1 CONSULTATION FEE _ &78.00/hr SAMPLING INSPECTION FEE = $78.00/hr $ <br /> TOTAL DUE $ Zo3Z� <br /> FOR OFFICE USE ONLY <br /> /-'§-WFEPS C ER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH ( RECEIVED SY DATE RECEIVED <br /> EH 23 032 (REVISED 6-21-93) Page 11 <br />