Laserfiche WebLink
8 <br />A <br />P <br />P <br />L <br />I <br />C <br />A <br />N <br />T <br />SAN JOAQUIN PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION <br />OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />FACILITY SITE NAMEnn <br />FACILITY CONTACT NAME <br />_ p/ <br />C.► F / Y <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />1987 <br />1 1988 <br />CITY 01 <br />STATE <br />ZIP CODE <br /># of TANKS <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />S <br />!x-633 a <br />7 <br />at SITE <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAM <br />MAILING ADDRESS <br />APPLICANT ONE # WITH AREA CODE <br />CITYed <br />STATE ZIP CODE <br />TYPE of APPLICATION <br />��l <br />qS'2 4) S.® <br />(Closure, Installation, etc.) <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br />L <br />1986 <br />1987 <br />1 1988 <br />1989 1990 <br />$ <br />I <br />R <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />S <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />R <br />XXXX <br />XXXX <br />XXXX <br />XXXX XXXX <br />$ <br />XXXXXXXX <br />A <br />C <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable)XXXX <br />XXXX <br />XXXX <br />XXXX I XXXX <br />$ <br />XXXXXXXX <br />I <br />V <br />TANK FEE = $50.00/TANK <br />(Prior to January 1,1991) <br />I <br />$170/TANK <br />(After <br />January 1, <br />1991) <br />E <br /># Tanks = —.2n — <br />1988 11989 11990 11991 <br />1992 <br />1993 1994 <br />1 1995 <br />1996 <br />1997 1998 <br />F <br />(multiply # by fee for <br />$ <br />A <br />each year applicable) XXXX XXXX 1 XXXX I XXXX +XXXX I I <br />C <br />I <br />TANK PENALTY FEES ASSESSED <br />XXXX I XXXX XXXX I XXXX <br />XXXX <br />$ <br />L <br />I <br />STATE SURCHARGE FOR NEW FACILITIES ONLY=$18.50 <br />$ <br />T <br />Y <br /># Tanks x $8.00 <br />1988 through 1993 <br />($56) <br />1993 <br />through 1997 <br />($56) <br />1998 <br />SURCHARGE FOR 1998 <br />XXXXXXXXXXXXXXXXXXXXXXXXXXX <br />XXXXXXXXXXXXXXXXXXXXXXX <br />$ <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br />L <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />0 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = <br />$ <br />I <br />R <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br />$ <br />S <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br />$ <br />P <br />L <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum <br />$ A a q- O 0 <br />R <br />E <br />REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />P <br />A <br />TANK LINING REPAIR FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = <br />$ <br />I <br />R <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br />$ <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br />$ <br />M <br />I <br />TRANSFER FEE = $20.00 ! UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />1 <br />$ <br />S <br />.............................................;..;......,................................................ <br />I CHECK #/CASH RECEIVED BY <br />DATE RECEIVED <br />C <br />CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = $78.00/hr <br />$ <br />TOTAL DUE <br />$ <br />FOR OFFICE USE ONLY <br />....:.,....:.:.....:::.:.....:.............................:.............,............................._.........:- <br />SWEEPS # <br />COMPUTER # <br />LOC CODE <br />..,....,....::::...;...,......,..__...,.......:::...........,............;.........................;._.__.........__.:,................ <br />DIST CODE AMOUNT RECEIVED <br />.............................................;..;......,................................................ <br />I CHECK #/CASH RECEIVED BY <br />DATE RECEIVED <br />:ss <br />EH 23 032 (REVISED 1-12-98) <br />