Laserfiche WebLink
SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL No DIVSION 4(D <br /> � /-'9+g7 <br /> UND RGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY, SITE NAME #,� <br /> NTACT AME q(, <br /> r � �i� IJ '_.(_ i ' 1`� 1-;` 7 C.CL1.t �—/ N �5 fZS <br /> E FACILITY ADDRESS /.l # with AREA CODE <br /> a l' l` `? •`�1G'c .�-}('j.} <br /> CITY STATE Zof TANKS <br /> F '/ '1 �'�ro.l (1 le SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> '� �L (1�l i� 1r---1 c L f t'_` <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> T CITY I STATE ZIP CODE TYPE of APPLICATION <br /> (i•. 1 <br /> RClosure) Installation, ate.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January i, 1991) = $100.00 1986 1987 1988 1 1989 1 1990 <br /> A $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) Xxxx XXXX S <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) 5 <br /> C <br /> 1 TANK PENALTY FEES ASSESSED XXXX XKXX 5 <br /> L <br /> 1 STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H 6 S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> S <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 minimm/TANK) # TANK(s)_Z X $234.00 .n- <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 5 Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimus f <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum f <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) X 5234.00 = 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 5 <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE 578.00/hr SAMPLING INSPECTION FEE = 278.00/hr 5 <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY <br /> ................................................................................................................................ ........................................................................................................................... <br /> z»a.n� . nsa.e.:niiw,.».. w�ww�..nn. ........».w,,..eu.»..».w.»....n...»»www»..»,. <br /> a <br /> » X <br /> um�e».n...roes«»e.»e...vw»sz.ms»w».mxe.:w.s»..rw».rwwsw.».r»x»w»ex..»r.www»».w»sx«riw xw«aw»wwww.w'iwr.rw.«»i.�w:w w.xw x..»ww xw•••• r.w..w..w»r <br /> _ :xsna xmxxa7mxwnxavxsarea�ron mxa�xaaaw+uaron�an neaoxmaaxar�tareaama#xwwxxaxmrenmxmarrsrrrrraarsnuMoxxa:xuwfarmarmxwrmw sar amen m.amxxexamrAw�arsxexwxw <br /> .' ---€H 23 032 (REVISED 3-1-93) • Paae 11 <br />