Laserfiche WebLink
SAN JOAQUIN CCUNTY PUBLIC HEALTH SERVICES - ENVIRON19EMTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SI FACILITY SITENAME Q FACI�LgITY CONTACT NAME <br /> I 4 /1 4f-r C1 i, - O <br /> T <br /> E FACILITY ADD(�E55 SIT PHONE 'J with AREA CODE <br /> f V L Q t J �6 n1t�L d L L C"" <br /> CITY STATE I IP CODE M of TANKS <br /> A ��,+— —ry.. ; at SITE <br /> P <br /> P APPLICANT/SILLING,NAME APPLICANT CONTACT NAME _ <br /> C MAILING ADDRESS APPLICANT PHONE N WITH AREA CODE <br /> LL', l ao - <br /> T CITY STATE ZIP CODE TYPE APPLICATION a R i fl lVy) <br /> [Uncal Latton, etc.) bac& <br /> 4 /16-LU TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 2100.00 1986 1987 1988 1989 1990 <br /> A XXXX 7CCO[ S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX X)00( S <br /> V TANK FEE = 550.00/TANK (Prior to January 111991) 5170/TANK (After January 1, 1991) <br /> E <br /> 2 Tanks = 1986 1987 1988 1 1989 1990 1991 1 1992 1993 1994 1995 1 1996 <br /> F (multiply #byby fee for <br /> A each year applicable) 7000( XX7IX ��� 3Yo� 2t[� ,-Z(i� f <br /> C JT J'`[ � i <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX 1 ,� ?('.0 7 Q S "1 <br /> L <br /> I STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California 4 3 S Code, Section 25287 <br /> T <br /> T x Tanks_ z $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) _ <br /> r <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. X(S) <br /> L <br /> l I <br /> SI CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) $ TANK(S) X 5234.00 <br /> UI I <br /> TEMPORARY CLOSURE (Plan Review 3 (nspections) TANK I.O. S(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimm/FACILITY) (234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review S Construction Inspections)I TANK I.D. 3(s) <br /> L <br /> A <br /> M PLAN CHECK FEE - 578.00/hwr (8 hours minimm/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review i Construction Inspections) TANK 1.3. f(s) <br /> E <br /> P TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) ! TANK(s) X 5734.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE - 578.00/hwr (3 hwn min./FACILITY) _ $234,00 mininam S <br /> R <br /> PIPING REPAIR FEE = S73.00/hour (3 hours miniaam/FACILITY) - 5234,00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION - $78.00/hr S <br /> I <br /> S <br /> CI CONSULTATION FEE = f78.00/hr SAMPLING INSPECTION FEE - $78.00/hr f <br /> TOTAL DUE f �. <br /> FOR OFFICE USE GILT <br /> SWEEPS 0 COMPUTER 9 LOC CODE DIST CODE I AMOUNT RECEIVED i CHECK ;*/CASH RECEIVED HY DATE RECEIVED <br /> S I _ <br /> v v <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />