COMPLIANCE INFO 1985 - 1997 - Laserfiche WebLink

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SAN JOAQUIN CC PUBLIC HEALTH SERVICES - ENVIRONMENTAL HE, DIVSION UNI, ,ROUND STORAGE TANK PROGRAM - FEE WORKSHEET S FACILITY SITE NAME /� FACILITY CONTACT NAME Y T 1988 1989 1990 R E ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 E FACILITY ADDRESS '/7 A/, z SITE PHONE # with AREA CODE E) - :-3a # TANK(s) X $234.00 = S S TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S �.On A CITY �6 Is TE ZIP CODE # of TANKS at SITE P GC R P APPLICANT/BILLING NAME APPLIC ONTACT NAME 1 $ T I C MAILING ADDRESSAPPLICANT _ PHONE # WITH AREA CODE �6 N 'o c s O17 q, fz—, 3 V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) E T CITE STATE ZIP CODE/TYPE of APPLICATION (Closure, Installation, etc.) TOTAL C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) 1986 1987 1988 1989 1990 R E ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 TANK I.D. #(s) 0 CLOSURE FEE = S78.00/hour (3 hours minimun/TANK) # TANK(s) X $234.00 = S S TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S �.On S A C TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ T I FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) E # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 F (multiply # by fee for S A each year applicable) C I TANK PENALTY FEES ASSESSED XXXX XXXX S L I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 T Y # Tanks x $56.00 1986 through 1990 1991 through 1996 (Enter amount and year) S C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) L PLAN CHECK FEE = 578.00/hour (8 hours minimxm/FACILITY) = $624.00 minimun S R E REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) 0 CLOSURE FEE = S78.00/hour (3 hours minimun/TANK) # TANK(s) X $234.00 = S S TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S �.On PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ P L INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) A N PLAN CHECK FEE = 578.00/hour (8 hours minimxm/FACILITY) = $624.00 minimun S R E REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) P A TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S I R TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = $234.00 minimum S �.On PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S I S C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S TOTAL DUE S FOR OFFICE USE ONLY ........................................................................................................................................................................................................................................................... Mn 1000 %OO(O %00 b<000 b00100000 b00 b00 )00000)O>O b0000 X00 JOU<61 % UJ000IJ00 fOC6 )00•.06 a`00 )O0000 bN )L<6G0 %00 %N I00o00 XOO )OfOtO T%� NV.t6 N00 )MOCO )Mf X�fO %OAb %06100000 %JO %OCOp %OO %00 )OOOCO>'00 )000?0100> )CNOO 1t�� M.roN MW )OM i0Nt0 %N HM .a� y3S �� 2 c 5 3y X36...i............................ �-7- �3 1 ........................................ (.................................................. ��..........................................................� %0D %0000:000 %0000 )000 io0000 b00 - )00000 b00IOO�W -- boo nf00o b00- bOCOO %04 JOOf00 %00 bOWO )0001000 V0000 N00 �Oo000 %00 %M00 N00 bW00 k00 )000 %Oo00 )000 %OWO K00 f00000 %00 b00 p0000 %oD bOWO b00 »W00 %00 JorooO )0001000 )OOooO Moo »M xcs xm z as xsaa nm azms sass ase )zmsas au rung ;Hs 2z;lm zu uau azz Z%ab= ata aaxa rue uatz ams ant a0aa au m sa ax age aim axaa s ac ou aaaas a e a ma ams R ens zex arez ran arias a es aas x u EH 23 032 (REVISED 3-1-93) Pace 11