Laserfiche WebLink
SAN JOAQUIN COI PUBLIC HEALTH SERVICES - ENVIRONMENTAL HES DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />I <br />FACILITY SITE NAME,� �a GIII� 4 ���� <br />U <br />FACILITY CONTACT NAME <br />T <br />I` ifee. <br />� <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br /># TANK(s) X $234.00 = <br />/�� !� <br />7CX� �' 1U�ernit� Ve . <br />Lei U3 1!769 <br />& <br />S <br />A <br />CITY <br />�nt�'GC► <br />STATE <br />�� <br />�IP CODE <br />!j� <br /># of TANKS <br />at SITE Z <br />R <br />P <br />E <br />TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) <br />PAPPLICANT/BILLING <br />NAME <br />APPLICANT CONTACT NAME <br />I <br />-H i1 j�P_`�i r Groo j i ; 6, <br />talc' 2 (3i,-rl o <br />C <br />MAILING ADDRESS <br />� �� , i ���� ra,s �� -# 42-o <br />APPLICANT PHONE # WITH AREA CODE <br />s i o� G"`� - ax! <br />N <br />� <br />T <br />CI Y <br />��)il(�r�� <br />STATE <br />ZIP CODE <br />614,32C") <br />TYPE of APPLICATION �orai�c;_on1� ; <br />G� <br />(Closure, Installation, etc.) `°�rlis� <br />TOTAL <br />1986 1987 1988 1989 1990 <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />A XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br />C <br />T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX $ XXXXXXXX <br />I <br />V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br />E <br /># Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />F (multiply # by fee for <br />A each year applicable) XXXX XXXX XXXX XXXX XXXX XXXX $ <br />C <br />I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX XXXX $ <br />L <br />I STATE SURCHARGE _ <br />T <br />Y # Tanks x $8.00 1988 through 1990 1991 through 1996 1997 <br />(Enter amount and year) <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXX $ <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />I` ifee. <br />� <br />H <br />0 <br />CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />S <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />$ <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />L <br />I` ifee. <br />� <br />H <br />PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum)( 5 <br />TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br />$ <br />R <br />PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br />$ <br />I <br />TRANSFER FEE _ $20.00 1 1 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I I I $ <br />CONSULTATION FEE _ $78.00/hr I I SAMPLING INSPECTION FEE _ $78.00/hr I I I $ <br />TOTAL DUE I $ <br />FOR OFFICE USE ONLY <br />EH 23 032 (REVISED 4-24-97) <br />