Laserfiche WebLink
SAN JOAQUINPUBLIC HEALTH SERVICES - ENVIRONMENTAL *H DIVSION <br /> AGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME �jq FACILITY CONTACT NAME <br /> I r3 /i'/fes I-k/g- <br /> E FACILITY ADDRESS / SITE PHONE # with AREA CODE <br /> & <br /> CITY L STATE ZIP CODE # of TANK <br /> AS f _ <br /> q752( at SITE /�,LJ <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L v(a� <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE I TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> � <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 1986 1987 1988 1989 1990 <br /> A XXXX XXXX I XXXX I XXXX XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX f XXXX ( XXXX XXXX , XXXX $ XXXXXXXX <br /> I <br /> V TANK FEE _ $50.00/TANK (Prior to January 1,1991) 8170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX ' ( S <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX I I I S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 is <br /> T <br /> Y # Tanks x 58.00 1988 through 1990 ($56) 1991 through 1996 ($56) 1997 <br /> I <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> CPERMANENT 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 5234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum 5 <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 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 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum S <br /> IPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S <br /> C, CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr S <br /> TOTAL DUE S 3 o_} <br /> FOR OFFICE USE ONLY <br /> ........................:sa:aa¢:a[:tt:¢:¢t= :::::¢::a-:s; <br /> .............................. ;mow€w :mss:€;-w_:—:- .- .... ::€=€_€-_`= _ ._. ......... '.•... <br /> SWEEPS # I COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED I CHECK #/CASH I _ RECEIVED BY- I_ _DATE RECEIVED -- <br /> S <br /> _.._ _............................................................................._.� :::_.._.,_:. . _....._................._.._.1._...........__............................................... <br /> ... <br /> EH 23 032 (REVISED 5-27-97) <br />