Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE FACILITY CONTACT NAME <br /> T a) Sv ` ` " <br /> E FACI ITY ADDRESS .� SITE PH NE # wig AREA CODE <br /> & t <br /> CITY ST E ZLP CODE # of TANKS ' tv t:,-�e-lYt.G�r�4° <br /> A a" l ``D at SITE :r.:11 —:z a f/ V>r <br /> P o <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> IL <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <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 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 = 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 $ <br /> C �✓ <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY = $18.50 E 565`i <br /> T <br /> Y # Tanks x $8.00 1988 through 1990 ($56) 1991 through 1996 ($56) 1997 <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX $ a <br /> or Authorized Closure-in-Place) TANK I.D. #(s) <br /> 1 7 (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> t f iiew & Inspections) TANK I.D. #(s) <br /> .00/hour (3 hours minimum/FACILITY) $234.00 minimum $ <br /> (r��rallci� <br /> 719 - 00+ <br /> < 170 -00+ an Review & Construction Inspections) TANK I.D. #(s) <br /> 170 - 00+ <br /> 8. 00+ it (8 hours minimum/FACILITY) _ $624.00 minimum <br /> 0 0 7 1 & Construction Inspections) TANK I.D. #(s) <br /> 1 ) 0 7 5 . 0 0*+ '8.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ <br /> $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> � .. .... ,hour (3 hours minimum/FACILITY) _ $234.00 minimum $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ <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 /> ......................................... ............................................................._......................_...................................................................._.................................................._....................................................... <br /> _................................................................................................................_._......._... .............................._....._._.-..............................................................................._............................................._...._............................................................... <br /> :::::::::::::::::::m:::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.::*E'D::::::'Y"':::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: <br /> SWEEPS # COMPUTER # LOC CODE DIS CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> i €'s€` '•i's€> i '`• •`•' �' € ' '` } .......................................... <br /> _€ E € .............................................i€i3€€€s`ii€ €€ <br /> EH 23 032 (REVISED 5-27-97) 7 <br /> 67 b CQ �• �—_ <br /> t I <br />