COMPLIANCE INFO_1986-2001 - Laserfiche WebLink

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SAN JOAQUIN CUTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH DIVSION GROUND STORAGE TANK PROGRAM - FEE WORKSH S FACILITY SITE NAME FACILITY CONTACT NAME T Q�1 STo P b AMAg /ti'MA A)UST Sl N(S&T "E FACILITY ADDRESS SITE PHONE # with AREA CODE 10 3n S a L VE AVE 2Cl-j 1 4-S -- (�,13 CITY STATE ZIP CODE # of TANKS A S-PoCkTv,,J Cid- qs 7 S at SITE Z P APPLICANT ILLING NAME APPLICANT CONTACT NAME wIA-U-11>,J &-r�r&f NA r ✓► (,-E &65 I C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A �o bz>>c l Dz S I mo- 3'7 3 't (6 a T CITY STATE ZIP CODE TYPE of APPLICATION C--Lo S V R-E" N �• sflC(LAM��,sza Gs� gS(oq (Closure, Installation, etc.) TOTAL 1986 1987 1988 1989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 A XXXX XXXX XXXX XXXX XXXX S XXXXXXXX C T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX XXXX E XXXXXXXX I V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # Tanks = 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 F (multiply # by fee for A each year applicable) XXXX XXXX XXXX XXXX XXXX $ C I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX $ L I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 $ T Y # Tanks x $8.00 1988 through 1993 ($56) 1993 through 1997 ($56) 1998 SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S C PERMANENT CLOSUR (Removal r Authorized Closure-in-Place) TANK 1.0. #(s) -7(o 7(► ^ 2 L / 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) Z X $234.00 S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) $234.00 minimum 5 P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) L A N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum $ R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) E P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S A I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum S R PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum $ M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $ I I ' S C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr 5 TOTAL DUE $ (o$, FOR OFFICE USE ONLY .«..«.....»........«.«..«...................................«................................««....... ....... ...............« ..................Y.:S.�::S««.'^«.'.«.:Si:«.........3«::::S:::S:i:i:•i•'.:.«....««..««. ....SAi. "»L.i«.......".••....•SS"..^.' :«�3:::::« .�«:::::::::«::::Y.::««« .....Si.........................«.«..........ii....i................................i........................«...tt.'��«....—:�«.n:::::........ ..«....�.;.:.-........«. ........... «». ...«.....«« .^.« ........... ................... ......i......« .««.«. «�..^.L'«:::«:«::::..::�'::.«.«�«i9::5:•'«':«.:L ii... .«...........«.«......«...«......«.««.«..L3.iiiL:...............L....C::i:«.«...«:« i«::(. 'S.^. ':' R�Ci::::::�.fi::::«3S«:SS:S:W»::i::i•.:«iL:islf•.:«:ii:i::i«S:ST.::«:«.«:«Si:•..::� "« ='.:i::i:i2:t�:: :««: SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATERECEIVED . S :::....«...«.........»«.........«« .........«......«............ ..«........». «. .... «. ........ «««............«.....«.. ....««.»..«...................«.i...i•..:SS:SSL^..:: «LY.^:S«::.^.«::::Y.:::::::ii:.:«.�.«^::LSC: :i:s:«332'i::.;..i..:iii:.i«iii::« ....5............i......................»...L...................i...........«.................LCS...SC.........Ltt«C«.....tit...................5.....«.....Lii«.t iCL .CS.LC.«..................................:i..i.... .3........55................... .....................«................«....................................................«.......«...................«.«......«...«.....................«...........«..«..».....«.«.........«...«...«....................«....;.....»..:Siii:::«:::':::::::.:::S:S««^::':«i'::::::::::«:::«S:'::::.'«::3::«:^.0:«L:.'C«::::. EH 23 032 (REVISED 1-12-98)