Laserfiche WebLink
SAN JOAQUIN aPUBLIC HEALTH SERVICES - ENVIRONMENTAL H�I DIVSION <br /> UND OUND STORAGE TANK PROGRAM - FEE WORKSN <br /> SFACILITY SITE NAME FACILITY CONTACT NAME <br /> 1ESI Aoo ^ <br /> T Kq� t T C-- 1 L�ol �t'o J o <br /> FACILITY ADDRESS �J 1 SITE PHONE # with AREA CODE <br /> -1 1 WA.54 PO rte. \ PJi qP cl r67- Z —I <br /> CITY STATE ZIP CODE # of TANKS <br /> A -) �. �33 at SITE ' <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I l- E S <br /> C MAILING^A�DDRE\SS !l ` (T,., APPPLIICANT PHONE # WITH AREACODE <br /> N -Logo (Qa10Ja MSS sv, 4� 1 n <br /> T CITY STATE ZIP CODG <br /> CODE TYPE of APPLICATION OSJ!-2 <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A xxxx xxxx xxxx %XXX xxxx S %%X%XXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx xxxx xxxx %%%x S %%%KKXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 <br /> F (multiply T by fee for <br /> A each year applicable) xxxx xxxx XXXX XX%x %XXX E <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx XXxX XXXX xxxx XXXX S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T <br /> Y # Tanks x 58.00 1988 through 1993 (856) 1993 through 1997 (556) 1998 <br /> SURCHARGE FOR 1998 XXXXxxxxxxxxxxxxXxxxxxxxxxx XX%x%XXXxxxXxxxxxxxxxxx E <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 minimum/TANK) # TANK(s) X $234.00 = S <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum E <br /> P INSTALLATION PLAN CHECK (Plan Review & 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 Y <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = $234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 878.00/hr S <br /> f <br /> S <br /> 1 I <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE $ Ob <br /> OFFICE USE ONLY <br /> _................................................................................................_._......._...._._..................__...................................................................__....................................._—._...___.__.__.......,.._.............................._........._....................................... <br /> .....__..._. .._.....___.._.— __..___......—_._.._....._....�—._. ..._........ ......_..._..,.. <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> E <br /> ...... ....... _._..._� —__ ...____--:::_-..__........_T...... <br /> EH 23 032 (REVISED 1-12-98) <br />