Laserfiche WebLink
SAN JOAQUIN CW'" IC HEALTH SERVICES - ENVIRONMENTAL HEA' j*SION <br /> UNC T STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ! SITE NAME FACILITY CONTACT NAME <br /> fL 1TY ADDRESS _- <br /> SITE PHONE #_with AREA CODE <br /> CITY \ STA ZIP CODE_ .. # of TANKS <br /> X <br /> at SITE <br /> P APPLICANT CON CT NAME <br /> P APPLICANT}/BILLING <br /> I APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS rr <br /> N <br /> T CITY } \ STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 2100.00 XXXX XXXX %XXX XXXX S <br /> A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) %X%% XXXX %XXX XXX% 3 <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> 9 Tanks 1986 11987 1988 tI <br /> 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for S <br /> A each year applicable) XXXX XXXX XXXX XXXX <br /> C y <br /> I TANK PENALTY FEES ASSESSED XXX% %XXX y�(X% %XXX <br /> L <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) 2 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s)_ % 2234.00 - 5 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK t.0. #(s) <br /> R S <br /> EI TEMPORARY CLOSURE FEE = 278.00/hour (3 hours minima/FACILITY) 3234.00 minimum <br /> EA LATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. #<s) <br /> S <br /> HECK CE <br /> = 278.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 378.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S <br /> A 3 <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours mini mum/FRCILITY) = $234.00 minimum 2 <br /> X TRANSFER FEE = 220.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr $ <br /> S <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr <br /> TOTAL DUE S <br /> FOR OFFICE <br /> USE ONLY <br /> DATE RECEIVt_e;:___ <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMWNT RECEIVED CHECK #/CASH RECEIVED BY <br /> EH 23 032 (REVISED 4-6-95) . . te� <br />