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P50/ -a73- <br />P rocKn bi <br />I NAILINGADDRE �� AP�� T PHONE # WITH AREA CODED <br />C GT <br />A <br />N CITY ^ _. /// q III Z�yC.OD'E_ TYPE of APP�I ALLA �� etc. <br />T ciF-cl/)/{.'.IJCYI. ,niJ/!1/VK•i(//J/L-/C�/, 1 CLOSURE STALLAT I(7P <br />TOTAL <br />A <br />C 1986 1987 1988 1989 1990 <br />T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />I S <br />V <br />E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br />F # Tanks r 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />A (multiply # by fee for 18115-0 <br />y <br />C each year applicable) 6 J S <br />I <br />L STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H b S Code, Section 25287 <br />I <br />T # Tanks -i x $56.00 1986 through 1990 1991 through 1996 <br />Y (enter :;;t t and year) <br />C <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />TANK I.D. #(s) <br />L <br />0 <br />ENVIRONMENTAL HEALTH DIVISION <br /># TANK(s) X 5159.00 = <br />S <br />UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br />FACILITY SITE NAME <br />A %a.E - <br />-Iva'od S i 5sy <br />FACILITY CONTACT NAME <br />Ha ;,tR- <br />nth <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br /># TANK(s) _ X $150.00 = <br />E <br />T <br />I FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />PLAN CHECK (Install. Plan Review 8 Construction Inspections) <br />TANK I.D. #(s) <br />q <br />PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = 5424.00 mini mm <br />Y CITY ` O <br />^A� <br />` F7 <br />ZIP CODE ( <br />�PAPPLI <br />atoSITEN <br />REPAIR FEE (workplan review 8 construction inspections) <br />A APPLICAANNTT/B—II/L—LING NAME <br />GUIT CONTACT NAME <br />TANK REPAIR FEE - $53.00 per hour (3 hours minimum/TANK) <br />P50/ -a73- <br />P rocKn bi <br />I NAILINGADDRE �� AP�� T PHONE # WITH AREA CODED <br />C GT <br />A <br />N CITY ^ _. /// q III Z�yC.OD'E_ TYPE of APP�I ALLA �� etc. <br />T ciF-cl/)/{.'.IJCYI. ,niJ/!1/VK•i(//J/L-/C�/, 1 CLOSURE STALLAT I(7P <br />TOTAL <br />A <br />C 1986 1987 1988 1989 1990 <br />T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />I S <br />V <br />E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br />F # Tanks r 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />A (multiply # by fee for 18115-0 <br />y <br />C each year applicable) 6 J S <br />I <br />L STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H b S Code, Section 25287 <br />I <br />T # Tanks -i x $56.00 1986 through 1990 1991 through 1996 <br />Y (enter :;;t t and year) <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X 5159.00 = <br />S <br />5 <br />U <br />R <br />TEMPORARY CLOSURE (A one-time permit, for review/inspections) <br />TANK I.D. #(s) <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br /># TANK(s) _ X $150.00 = <br />E <br />T <br />FEE = S 53.00/hr <br />P <br />L <br />PLAN CHECK (Install. Plan Review 8 Construction Inspections) <br />TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = 5424.00 mini mm <br />S <br />R <br />E <br />REPAIR FEE (workplan review 8 construction inspections) <br />TANK I.D. #(s) <br />P <br />A <br />TANK REPAIR FEE - $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X $159.00 = <br />S <br />1 <br />R <br />PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = $159.00) <br />g <br />N <br />I <br />CONSULTATIONS <br />UNAUTHORIZED RELEASE EVALUATION <br />SAMPLING INSPECTION <br />S <br />C I <br />FEE = 553.00/hr <br />FEE = 553.00/hr <br />T <br />FEE = S 53.00/hr <br />TOTAL DUE i S <br />OFFICE USE ONLY <br />