Laserfiche WebLink
SAN JOAQUIN C . PUBLIC HEALTH SERVICES - ENVIRONMENTAL H I DIVSION <br /> Ui.. XGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME I FACILIT//Y CONTACT NAME <br /> I Y_E� C G cTu tJcz c O <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & 14-140 LAI. C `!Z <br /> CITYc L STATE ZIP CODE # of TANKS <br /> PJ / c� f U h ccs y>-2-o c at SITE ^ <br /> P APPLICANT/BILLING NAM9 APPLICANT CONTACT NAME <br /> I c -�I �-, s <br /> L �-, C p; <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> T CITY STATE ZIP CODE TYPE of APPLICATION y <br /> / F'� nth <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 $ <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX $ <br /> I <br /> V TANK FEE = $50.00/TANK (Prior to January 1,1991) 3170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED I XXXX XXXX I $ <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) <br /> 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 378.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> PIINSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> Ll I <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum S 3 U <br /> Mi TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr 5 <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr $ <br /> TOTAL DUE <br /> FOR OFFICE USE ONLY <br /> :: ............ ::::t:s:t::::s::s::::::t:t::: .............*..........:s:¢:F <br /> SWEEPS # COMPUTER # I LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> ;s <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />