Laserfiche WebLink
/V J <br /> SAN JOAQUIN COLINLIC HEALTH SERVICES - ENVIRONMENTAL HEAMSSION <br /> UNDERJO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> �i FACILITY foj ME FACILITY CONT, NAME <br /> ` C7 <br /> E FACILITY ADDRESS,, 11 SITE PHON f with AREA CODE <br /> 3 31Pt)r (� �fCc� �� \VN <br /> r <br /> -I�j ST TE ZIP CODE * of TANKS fa <br /> P CITY (��G fW� �S of at SITE <br /> A J l <br /> C�V <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT <br /> SME <br /> L _ \ <br /> I <br /> C MAILING ADORE !. APPLICANT PHONE X WITH AREA CODE - <br /> L, S� (q I I �81-7�a')-- - V <br /> T CITY ST TE ZIP CODE TYPE of APPLICATION R C I_ <br /> S (Closure, installation, etc.) (nT ,� <br /> TOT <br /> 1986 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) : $100.00 1487 1988 1989 1990 <br /> A f <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXX( S <br /> I <br /> v TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> Tanks = 1986 1987 1988 1989 1990 1991 1992 1 1993 1994 1 1995 1996 - <br /> F (multiply 0 by fee for <br /> A each year applicable) (7 $I D 00 38 <br /> tTANK PENALTY FEES ASSESSED XXXX XXXX S <br /> L <br /> LL::: E <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H b S Code, Section 25287 <br /> T <br /> Y x Tanks x (56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L5� <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimuNTANK). f TANK(s) 3 X 5234.00 = O 0� <br /> U TEMPORARY CLOSURE (Plan Review R Inspections) TANK I.D. #(s) 77 <br /> R <br /> E TEMPORARY CLOSURE FEE _ %78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum f <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. 1(s) <br /> L <br /> N PLAN CHECK FEE _ %78.00/hour (8 hours minimum/FACILITY) = 2624.00 minimum S 00 owl I <br /> R REPAIR FEE (Workplan Review b Construction Inspections) TANK I.D. 2(s) <br /> E <br /> P TANK LINING REPAIR FEE = 178.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = f <br /> A <br /> I TANK RETROFIT REPAIR FEE _ %78.00/hour (3 hours min./FACILITY) _ $234.00 minimus f <br /> I <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimLWFACILITY) : $234.00 minimum 5 <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr f <br /> t <br /> S <br /> C CCNSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr S <br /> TOTAL bUE f <br /> FOR OFFICE USE ONLY <br /> MO.,.,.,..».»,...»M..�1...,...........».........»».»,.».a.�o»�..qc»M...»M..».»M..».»M....».M....».»»M«».»,'..p.�»tM»..»..»..■.M...IN.■...»,...»»».�». _...�»..»M..11.......» <br /> a `Scr`S n"` Cl (Ei <br /> EN 23 032 [REVISED 3-1-931 � � ��yyL; <br /> E <br />