Laserfiche WebLink
SAN JOAOUIN COUL <br /> IC HEALTH SERVICES - ENVt TAL IVSION <br /> UNDE STORAGE TANK - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I &r—is- (f wA-S tfS T(A <br /> 'E FACILITY ADDRESS /� n SITE PHONE # with AREA CODE <br /> 51" �c• /� QMrt 209 <br /> CITY C / rSTATE Z CODE # of TANKS <br /> A VTa�+�S�01� inj '/�2A at SITE 3 <br /> P I <br /> P APPLICANT/BILLING NAMEAPPLICANT CONTACT NAME <br /> L Q QF <br /> Fll IF> <br /> I <br /> C MAILING ADDRESS 1i ' �( APPLICANT PHONE # WITH AREA CODE <br /> A 40 • S W� I 2 b _ Q <br /> T CITY �-•� STATE ZIP CODE TYPE of APPLICATION C�®`JVf� <br /> '5 �Q►� 1 5 24 (CIQ,SIiCS�Installation, etc.) <br /> TOTAL <br /> 1486 1487 � 1988 11989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX XXXX XXXX XXXX I XXXX S XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX I XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1988 1989 1 1990 1941 11992 1 1993 1 1994 1995 11996 11997 1998 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX I I I I S <br /> I TANK PENALTY FEES ASSESSED ' XXXX I XXXX I XXXX I XXXX (XXXX I I I ( S <br /> L <br /> I STATE SURCHARGE FOR NEW FACILITIES ONLY=518.50 S <br /> T IY # Tanks x 58.00 1988 through 1943 (556) 1993 through 1947 (S56) 1998 <br /> SURCHARGE FOR 1998 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX S <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) I TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s) 2? X 5234.00 = 5 o Q= <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = 5624.00 minim S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minim/TANK) # TANK(s) X 5234.00 = S <br /> A <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = $234.00 minim $ <br /> N TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I i <br /> S <br /> C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE - 578.00/hr I 5 <br /> TOTAL DUE IS 76' <br /> FOR OFFICE USE <br /> nONLY <br /> _- ,� ...e a:e:::..:G:.:•::- _�--= ; ��- <br /> mmat3r�'ssasm 'frscs£ua:=_as' i?iu_e-�• »•' <br /> - SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED i CHECK */CASH RECEIVED BY DATE RECEIVED <br /> i3 :tf <br /> m: <br /> :........�::-.....ri..-a::.:2 `i=i:ii-«'•'cRiSE.:ms'».•'•3!:L?£Ri'?_n'.sr..-t."'•3i'ii?'::aSi_:-i;;:;.;--reasaes...._y:Vin :=:r•-r:a—�i?s=••y:...-r.�•.•.».».. .ter.•_...—nomxis,,..._...•`,•:•^„-:s:::s'c: =•�:a-xr-........._.. <br /> :::::arms•...:�:a•»:mn••.r•...:•r»r... ....... .»..».» <br /> ::s-::^s:r».;r'r...»�...:•c:mii=ii »:...,«._..;»�..:.: ... •.... __••::.^•i�..e;........... _...._..._... ... .»_..r.= s:�:�.- ?a:tE•-: <br /> ?a.:t.e.ms_::—zm:—:.-:.=-::ac:c.•s_^�.�•m»•se»•s:sn.[:z....r...».s;.......;..�mcs=•::::.�.»::.r.:::::�r.^....___'.:^._�:c:.••--s^....^x <br /> cu �� nl;) (RFVISFD 1-12-98) <br />