Laserfiche WebLink
SAN JOACHI M NTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL LTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> / <br /> SITE NAME FACILITY CONTACT NAME <br /> Golf and Country Club <br /> ;TY ADDRESS SITE PHONE # with AREA CODE <br /> J Chrisman Road <br /> ( STATE ZIP CODE # of TANKS <br /> acy CA 95376 at SITE 1 <br /> tPPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> .A <br /> M <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1987 1988 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 1986 1989 1990 <br /> A $100 $100 $100 $100 $100 S 500.00 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) 5100 $100 $100 5100 5100 S 500.00 <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year app(icable) $50 $50 550 $50 $50 S 250.00 <br /> C <br /> ITANK PENALTY FEES ASSESSED $50 $50 $50 $50 $50 S 250.00 <br /> L <br /> 1 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks 1 x 856.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S56 S 56.00 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) �� <br /> L +�1 b7 <br /> 5 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s)_1_ X $234.00 = S 234.00 p- <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) = $624.00 minimum 5 <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK [.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm!/FACILITY) = $234.00 minimum S <br /> MTRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S 1790.00 <br /> FOR OFFICE USE ONLY <br /> _..__.._. ..__..........................:..............:...:..__..._._.__........... ..-.......:.........._........_.._............_..._..._...:_.::__:::;__,::....' . _ .....................— <br /> T.::.:::::::� . . <br /> .......... ::::...::::::::::: <br /> u!!!!::_!!_:::__:::.-:::=:=_a. r—_!!u�:;�:!!!!!•��:_s!!�!!�a:_�:::::-!c:::._!r::::::!!!: : �_::iRitiiiR'_i <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED = <br /> 5 <br /> . <br /> _ v.:._ �..___..._..._._... ........ <br /> ....._._.... <br /> .___._._:IL'e" <br /> ppp <br /> EH 23 032 (REVISED 4-6-95) AI\� <br />