Laserfiche WebLink
SAN JCAOUIN cGUNYy�IC HEALTH SERVICES - EAVIROMMENTAL HEALTHIOM <br /> UMDEA STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SI FACILITY SITE NAME I-TFAACILITY CONTACT AMIE 7,75 <br /> T I <br /> SITE PRONE @ with AREA C00�� o <br /> E <br /> FACILITY ADDRESS <br /> dSTATE 2IP CODE a of TANKS <br /> A CITY) + , +. y ,rh at SITE <br /> P ^ � l APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I I APPLICANT PHONE )t WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N STATE 2IP COKETYPE of APPLICATION <br /> T) CITY ✓ I I (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 11987 11988 11989 11990 <br /> I ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 KXXX I %xQ I I S <br /> A <br /> C I XXXX I pool I I I T <br /> T FACILITY PENAL77 FEES ASSESSED If Applicable) <br /> 1 1,1991) 5170/TANK (After January 1, 1991) <br /> V TANK FEE = S50.00/TANK (Prior to January <br /> E R Tanks 1986 11987 11988 11989 11990 11991 11992 11993 11994 11995 11996 <br /> = <br /> F (=Ctit)LY 7Wfee for I I I I I I I I S <br /> A each year applicable) %XXX XXXX <br /> T <br /> ( iANK PENALTY FEES ASSESSED I XXXX I XXXX <br /> I I I A <br /> L <br /> 11 STATE -URCMARGE = S56.00 eacn TANK (Due every 5 years) See California H 3 5 Code, Section 2528 <br /> i1988 through 1990 1991 through 1996 <br /> s <br /> Y $ Tankz 556.00 T <br /> (Enter amount and year) <br /> Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> TANK I.D. $(a) <br /> Lx TANK(S)- X 2234.00 <br /> mlTANK) = T <br /> 0 CLOSURE FEE - S78.00/hour (3 hours minim <br /> Stiara) TANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review d Inspec T <br /> R <br /> EI TEMPORARY CLOSURE ;E-- = S78.00/hour (3 hours mininnm/FACIIITY) 5234.00 minimum <br /> PI INSTALLATION PLAN CHECK (Plan Review d Construction :nspections)I TANK I.D. !(s) <br /> L T <br /> A = S624.00 minim, <br /> Mi PLAN CHECK FEE = 278.00/hour (8 hours mi nimm/FACILITY) <br /> IRI REPAIR FEE (Workplan Review d Construction Inspect ions) TANK I.K. 3(s) 5 <br /> E X 5234.00 = <br /> PI TANK LINING REPAIR FEE = 5$.00/hour (3 hours miniinm/TANK) I 9 LANK(s) S <br /> A = 5234.00 minimum <br /> t TANK RETROFIT REPAIR FEE - 5$.00/hour (3 hours min./FACILITY) T <br /> R <br /> PIPING REPAIR FEE = 5$.00/hour (3 hours mini mm/FACILITY) _ s234.00 minim, <br /> I <br /> MI TRANSFER FEE = T20.00 I I UNAUTHORIZED REUSE EVALUATION = T$-00/hr I ) <br /> I I S <br /> S I I SAMPLING INSPECTION FEE • S$.00/hr <br /> Cl CONSULTATION FEE = S78.00/hr <br /> TOTAL DUE T <br /> FOR OFFICE USE ONLY crtTVFn <br /> _ -- — <br /> RECEIVED rNES */CASH RECEIVED 3 � _ <br /> ATE SWEEPS S COMPUTER = LOC :COE DIST uz+c ^. ___ <br /> H :3 032 (REVISED 10-28.03) 3 <br />