Laserfiche WebLink
SAN JOAQUIN C Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL V -H DIVSION <br /> UA:axGRCUND STORAGE TANK PROGRAM - FEE WORKSHEET-- <br /> TFACI STT SITE N FACILITY CONTACT NAME .^C� <br /> E FACIL TY ADDRESS IT PHONE # with AREA CODE <br /> CITY Kw1 1�t, � � TATE P CODE # of TANKS <br /> A �. ` 1 at SITE <br /> P `- <br /> P APPLICANT/ LING NAME / APPLICANT CONTACT NAME <br /> L : <br /> 1 <br /> C MAILIN ADDRESS / APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY r/ ♦ STATE 2 P CODE TYPE of APPLICATION <br /> -4f, .�' (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = SJOO.00 <br /> AXXXX XXXX <br /> C D /00 f <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX v(] /001 f <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 3170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 2— 1986 1987 1 1988 1989 1990 1991 1 1992 1993 1 1994 1995 1996 <br /> F (multiply # by fee for <br /> C each year applicable) XXXX XXXX / �jlw .uyo D <br /> Is <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX (] f <br /> L' <br /> ll STATE SURCHARGE = 356.00 each TANK (Due every years) See California 4 3 S Code, Section 25287 <br /> T <br /> T # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. #(s) <br /> L <br /> 01 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234,00 = f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) (' n # s) <br /> R V <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimm/ ACI 34.00 minimum f <br /> PI INSTALLATION PLAN CHECK (Plan Review i Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> M PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum f <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.O. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 3234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> I PIPING REPAIR FEE = 378.00/hour (3 hours minimm/FACILITY) = S234.00 minimum 3 <br /> Al TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = 378.00/hr $ <br /> I <br /> S <br /> Cl CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = S78.00/hr $ <br /> rTOTAL DUE f <br /> FOR OFFICE USE ONLY u'D,8`-(..... ' 1.. L' � <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY GATE RECEIVED = <br /> _i <br /> _. -...__....... --....................__._......- -........__._. _... ...._.....r............_.... - <br /> EH 23 32 (REVISED,10- 8-93) Page 1 <br /> l <br />