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SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRCUND STORAGE TANK PROGRAM - FEE 'JCRKSHM <br /> F <br /> FACILITY,SITE NAME FACILITY CONTACT NAME <br /> //��� <br /> C L�\ \O �h; C) �O <br /> 1 FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> I <br /> T CITY STATE ZIP CCOE # of TANKS <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I HAILING 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 /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> 1 S <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TARK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996- <br /> A (multiply # by fee for <br /> C each year applicable) LA S <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T 1 # Tanks x $56-00 <br /> 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 5 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = 5 <br /> O <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> H PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = S424.00 minimum S <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimaNTANK) # TANK<s) X $159.00 = S <br /> A —' <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = S159.00) S <br /> N CONSULTATICNS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> 5 <br /> C FEE = S53.00/hr FEE = S53.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE S -A 00 <br /> OFFICE USE ONLY <br /> __........_...._........_......_.._....__......__.._...._........_....................__........_........_.............._._............._............ <br /> ...................................._.............................._........._.._ <br /> c ne <br /> 'a <br /> LYk 1 5 y-�� x� 2ctgt <br /> E...._.._..........__. .............._.... ....._.... .............1.......... ...... ................ ...........................................3 <br /> 1111 ifYt;O®IWINiY]1:16 WKW1MF491Y WN Wi]t1¢1i Zf4NY Mc M4 YrAHi i1{AIPi AMi at1i11f(HY}YillYi Ali'MlV lilt OliAYi •=LXNi9Y�YWAMR YtPilfli aw«a1wiM]Rt <br /> EH 23 032 (REV 1/10/911 ft Pace 11 <br />