Laserfiche WebLink
SAN JOAQUIN CCUM" PUBLIC HEALTH SERVICES - ENViRCNMENTAL HEA TH OIVSION <br /> UND OUND STORAGE TANK PROGRAM - FEE WGRKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I �� l G 1 PAt, `J U 1 G�1J� D N►J IS GAc l�(.Dr1.1' <br /> E FACILITY ADDRESS SIT-- PHONE » with AREA CODE <br /> g I�3I �. Ac}! � �>✓ ZD°1 333-&SOD e U <br /> CITY STATE ZIP CCOE " of TANKS <br /> A � t CIA at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L G 1'�`( tX W D 1 DEN►J�5 I.t�lrE{- tJ <br /> I <br /> C MAILING ADDRESS A PLICANT PHONE » WITH AREA CODE <br /> A 0. 6� 3a0(o � 333-(r$OD (off D <br /> N <br /> T CITY STATE ZIP CCOE TYPE of APPLICATION <br /> L--D t> 1 C� �52� 1 (Closure, Installation, etc.) f- PA(()-- <br /> TOTAL <br /> A(()-- <br /> TOTAL <br /> 1986 11987 11988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A I XXXX XXXX I XXXX XXXX I XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) I XXXX I XXXX XXXX XXXX I XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) I 5170/TA4K (After January 1, 1991) <br /> E� <br /> » Tanks = 1988 11989 1990 i 1991 11992 11993 11994 11995 11996 1997 1998 <br /> F (multiply » by fee for <br /> A each year applicable) XXXX XXXX I XXXX I XXXX XXXX I I I S <br /> CI I I i <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX I XXXX I XXXX (XXXX S <br /> l <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=S18.50 S <br /> T J <br /> Y » Tanks x 58.00 1988 through 1993 (S56) 1993 through 1997 (556)1 1998 J <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Remova( or Authorized Closure-in-PLace) I TANK I.D. »(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I » TANK(s) X 5234.00 = S <br /> S <br /> Ul TEMPORARY CLOSURE (PLan Review 8 Inspections) I TANK I.D. »(s) <br /> R <br /> r (3 hours minimum/FACILITY) 5234.00 -�inimum S <br /> EI TEMPORARY CLOSURE FEE = 578.00/hou <br /> P INSTALLATION PLAN CHECK (PLan Review 3 Construction Inspections)I TANK I.O. »(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.001hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FE. (Workplan Review 3 Construction Inspections) TANK I.J. »(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 = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S -7-?j 0� <br /> R <br /> PIPING REPAIR FE. = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimi-n S <br /> M TRANSFER FEE = 520.00 I I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> Ir <br /> 5 <br /> C CONSULTATION FE_ = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S 2 0 O <br /> FOR OFFICE USE ONLY <br /> _......_........ <br /> _.__......... _.........................................................._......... <br /> .................._...._..........__.._ <br /> ........................................................................_..........-._...._._-....._� _�:�___�_-:::_::�__�•::._::..1.—�_:�-_—:—•mac....._---.—_..._._.......---- C�I VE7 <br /> SWEE?S » I COMPUTER I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK ./CASH I R_CcIVEJ 3Y I DATE RE c <br /> Li <br /> EH 23 032 (REVISED 1-12-98) <br />