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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F / <br /> A V <br /> C <br /> I FACILITY /RESS SITE PHONE # With AREA CODE <br /> T CITYTE ZIP CODE # of TANKS / <br /> Y C sa� at SITE <br /> A APPLICANNTIBILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> IOD 100 /00 OT L <br /> A V ma <br /> C Q 1986 1987 1 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> 1 (UO 1 16)61106 1) 00 /00 550 0 <br /> V <br /> E TANK FEE = S50.00/TANK (prior to Jan ry 1,199 ) 5170/TANK (after January 1, 1991) 0 <br /> F # Tanks = 1986 1987 988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> y <br /> A (multiply # fee for <br /> C each year applicable) 56 156156 156 16011-101 1 1 1 1 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S(o — I fl S6' Sl/a <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) 9 TANK(s)_ X $159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X 5150.00 = 8 <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = S424.00 mini MUM S <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) _ X $159.00 = S <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = 8159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S 0 <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> .....x.e..w..»eee»w.eeexe.»»»eaexay.:u.xeaeme:ao:�am.�ucneen:w<ewexee:awexnewe«e we««e:w.:n«e:wexa:exee mowxe:oo.weo.:w.x»wweeeee.o.e e...»xe...»w.z»xeasxe..» <br /> S <br /> s...................... ........................ ....................... ........ <br /> .... <br /> ...................... ........... <br /> ....�w.o... xeo...»..»z».a..w......xezw.e.a "zexe aii:ir+i.wwewraexee xwenxro .•.......••...... ••••••••• .•.••..•.••..•••_••••••••••••••••••••••••••••••••.•.••.••• <br /> •. x<n:m.ew 'ieeew.wx...»..aae,«......«.....«....a.....xe...».» <br /> sroasanmacwxanxxxaaxmxasamraaasamaxxmxmmaixvax�ax:zxxtt�ntt urrssxxx�s:,:sa><;� �:".„ms;asnrsttn�s aysmnesmrossxrxwrsxrcawxraaesxrwxawanw <br /> cu J2 nxe ,acv 19 AA,On� t. Oenn 11 <br />