Laserfiche WebLink
SAN JOAQUIN COD PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEO DIVSION <br /> UNDERGROl11D STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME ^ , <br /> S FACILITY SITE NAME ' / •� / <br /> I '%e, 4 1' <br /> /✓ i SITE PHONE # with AREA CODE <br /> E FAC lLITY ADORES`LF ( / �� ,Tl Lr 1� t G ,. L/ (: •� `� ,5' <br /> & - STATE ZIP CODE # of TANKS <br /> CITY at SITE <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY (Closure, InstaLLation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> LFACILITY <br /> ITY FEE (Prior to January 1, 1991) = 5100.00 XXX% XXXX I S <br /> A <br /> C I %x%x xxxx I S <br /> TALTY FEES ASSESSED (If Applicable) <br /> I 5170/TANK (After January 1, 1991) <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) <br /> E 1986 1987 1988 11989 11990 1991 1992 1993 1994 1995 1996 <br /> # Tanks = <br /> F (multiply # by fee for I I E <br /> A each year applicable) %XXX XxXX <br /> I I 5 <br /> I TANK PENALTY FEES ASSESSED XXXx %x%X <br /> L <br /> 1 STATE SURCHARGE = $56.00 each TANK (Due every S years) See California H & S Cade, Section 25287 <br /> T1988 ihrou9h 1990 1991 through 1996 +NV <br /> Y # Tanks_ z (56.00 <br /> (Enter amount and year) �` OIL <br /> bac <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) -3to7 <br /> L # TANK(s) �U X 2234.00 = S G G �- <br /> 0 CLOSURE FEE (78.00/hour (3 hours min imun/TANK) 'TN✓ <br /> STANK (.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) 1011 <br /> RS <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours mint FACILITY) I 5234.00 mini mum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A = $624.00 minimum 5 <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minis n/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E S <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimun/TANK) # TANK(s) _ X 5234.00 = <br /> A S <br /> 1 TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 mini num <br /> R S <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimutn/FACILITY) = 5234.00 mininun <br /> Ni TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> 5 <br /> 1 <br /> S = 578.00/hr I S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY " <br /> __... .._._._... <br /> ED <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE I AMOUNT RECEIVED CHECK #/CASH I RECEIVED BY GATE RECEIV <br /> L <br /> ...___......._..........................................._.. ...............................__._..._.....__.. ......___..................__...._............._...._._.........,:__::..,::_-_______::-.-::::::--::_:-::::.—.ter:.=�_......__- <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />