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SAN JOAQUIN CCUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRCUND STORAGE TANK PROGRAM . FEE wORMEET <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAME r ' <br /> C SITE PHONE Y with AREA CODEN <br /> 1 FACILITY ADDRESS5 <br /> T N ST�jZE IIp CODE Y of TANKS <br /> CITY n <br /> �/r YI SITE <br /> A APPLICANT/PILLING NAME - APPLICANi CONTACT NA9 <br /> P /�Ii1-T T/moi.✓ <br /> L APPLICANT PHONE Y Y TO AREA LODE <br /> I MAILING ADDRESS <br /> C ��j ' / '/ bh 4 - �lZ�j�' 9' ,j,3 <br /> `r 7� W /7 T /"Y <br /> A SATE ZI CODE TYPE of APPLICATION <br /> I <br /> CITY ma/)�-[.iO "3s- CLOSURE, INSTALLATION,ICN, •ic. <br /> /„ '/ J( TOTAL <br /> A 1984 1967 1944 1989 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to Jamary 1, 1991) • 5100.00 raP� klx, i <br /> I — -- --- <br /> V <br /> E TANK FEE • 550.00/TANK (prior to Jarwary 1,1991) 5170/TANK (after January 1, 1 1) <br /> F M Tenkx 7- T— 1986 1987 1988 1999 1990 1991 1992 1993 1994 1995 1996 <br /> A (Wi tiply / 6y fee for In 5 <br /> c each year appllcootc) <br /> I <br /> L STATE SURCHARGE • $56.00 each TANK pus every 5 years) Sae California H i S Coda, Section 25287 <br /> 11991 through 1996 <br /> T ♦ Tanked_ R 554.00 1994 through 1490 <br /> Y (enter mont end year) <br /> PERMANENT CLOSURE (RC WVa( or Authorised TANK TANK I.D. #(a) <br /> C �� DD <br /> L CLOSURE FEE • $53.00 per hour (3 hour* minimus per TANK) M TANK(i) % 5159.00 5 <br /> 0 <br /> $ <br /> U TEMPPi(ARY CLOSURE (A one-tiam permli, for review/InspectIQm) TANK I.D. E(c) <br /> R <br /> E TEMPORARY CLOSURE FEE • $150.00 each TANK TANK(s) % $150.00 • S <br /> P PLAN CHECK (Irsgll. Plan Review 5 Constrtrctlon irwpect Torsi TANK I.D. MU) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (4 hours minlaum per Facility) • 5424.00 minlaus i_ <br /> it w REPAIR FEE (workpl'n review 5 cons tructlan Inspections) TANK I.D. Y(a) <br /> E <br /> III P TANK REPAIR FEE • 553.00 per hour (3 hours mi ntauNTANK) M TANK(a) X $159.00 i <br /> A <br /> I <br /> R PIPING REPAIR FEE + $53.00 per hour (3 hour minima per facility • $159.00) 5 <br /> N CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> i <br /> 5 <br /> C FEE • 553.00/hr FEE = 553.00/hr' FEE • S 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY ."��� <br /> r�r _7C. <br /> ., ._ .. <br /> � 'r,... ef•SI C �LM� /ti l KCLCIYCY ar ser <br /> Y,1i E'�lece Luca Mw <br /> s _ �. .. . ...._ e <br /> ..��>?.. .. ........... .�.��- .. s. 3.1`r�..:�.. 3.1......... . ............... ... .l..t.. .... .. <br /> EN m oil <br /> aiirir•:wrMarMwrwMrrrMrr rwMr•rwMs eerae•rerrerrarrM•rM.errMsr rM�:•wL'i <br /> to" 1110/91) ft Psoe 11 n 70 <br />