COMPLIANCE INFO_1991-1994 - Laserfiche WebLink

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SAN JOAQUIN A PUBLIC HEALTH SERVICES - ENVIRONMENTAL OH DIVSION UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET S T FACILIT ITE NAME ` f [16611� �� 1 �� I ( ITTY CONTACT AME FACIle--W L72 L1 1�rl2j 1986 1987 1988 E FACILITY ADDRESS SITE PHONE # with AREA CODE r,2(C,0 1 & CITY Cv STATTEZIP 4A CODE # of TANKS( at SITE 2) P l�t�(�� J t XXXX VIC- V _ I J� /16 U P I'<S�� APPLICANT/BILLING NAME APP CANT CONTACT NAME L (LL— C MAILING ADDR SS APPLICANT PHON#WITH AREA CODE N E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) T CITY STATE ZIP CODIC 7YP APPLICAT etc.) I�5/ V� /i T FACILITY PENALTY FEES ASSESSED (If Applicable) TOTAL PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) 1986 1987 1988 1989 1990 ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S XXXX XXXX U S <--� A R E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) C $ T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX S I V TANK FEE _ $50.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) E # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 U19 D(41�1 F A (multiply # by fee for each year applicable) XXXX XXXX I $(� C I TANK PENALTY FEES ASSESSED XXXX XXXX $ L 11 STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 jr1J�1 �� jbg T Y # Tanks,. x $56.00 1988 through 1990 1991 through 1996 :hfd* 01A<jb1 (Enter amount and year) /j C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) L PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum 0 CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S S U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) R E TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum $ P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) 2 DO !g M PLAN CHECK FEE = $78.00/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 = $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = $ A I TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) = $234.00 minimum $ R PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S N TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr $ I S C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = $78.00/hr S TOTAL DUE I S [6-7(p.00 FOR OFFICE USE ONLY EH 23 032 (REVISED 10-28-93)