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SAN JOAOUIN COUNTY PUBLIC HEALTH SE V C L1 <br /> ENVIRONMENTAL <br /> UNDERGROUND STORAGE TANK - F R H <br /> FACILITY SITE NAME jFjQjLIj�qTNTACT NAME(�. I ooN Sr, c tip EALTH <br /> L FACILIT( 1�ADOR�SS n ET �ERr. .>(IJ5@!@W th AREA�CODE <br /> 3 - O� <br /> T CITY Uv ` ✓` ATE ZIP CODE N of TANKS <br /> Y Y_To tJ at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> �L ' �r7 r�5 i 2LlCTtt�rJ — TJX <br /> L <br /> I RAILING ADDRESS ` APPLICANT PHONE d_ 1lITHAREi1 2-0 3 <br /> n 2 F�..A2�1� �W 7-�J - • %C�C/l `/�.,TFJ�/o_ (d <br /> N CITY 11 i1 p TATE Zjq_�D� TYPE of APPLICATION <br /> v LJ 1I L1 �/i�[� OEURE INSTALLATION, etc. <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 f <br /> v <br /> E TANK FEE S50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F 0 Tanks = 1986 1987 1988 1989 1990 1 1991 1 1992 1993 1 1994 1 1995 1996 <br /> A (mTltiply 1Y by fee for <br /> C each year app(icable) f <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 /> E <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(a) <br /> C <br /> L CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) N TANK(s) X $159.00 = $ r ' <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. N(a) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK N TANK(s) X $150.00 = E <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. M(a) <br /> L <br /> A <br /> N I PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 mini mm $ <br /> R REPAIR TANK I.D. N(a) <br /> E <br /> P TANK REPAIR FEE • $53.00 per hour (3 hours minimum/TANK) Al TANK(s) _ X $159.00 $ <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) S <br /> M CCNSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> $ <br /> C FEE _ $53.00/hr FEE _ $53.00/hr FEE = E 53.00/hr <br /> TOTAL DUE S + '. <br /> OFFICE USE ONLY <br /> .............._........_.._................................................................................................................................................................................................................................. <br /> m.=a..e..r.,.•rrw=nrr..»r.ww=e.x«rowewaeme=e.roxexmsae; :«.wra..,xe:e»»:«ee:w.rxxeweaw:wun wwx»:er rcaw w».» ........... <br /> i%umv le""Url"e rffIMT' � E`fi cB E.�:Iy:k i�ri7.;�:���..: :.ENE�i'T7a'Ldi`�;m,"'�` )mr��am➢?AWfffflE�°"`wfff9l'' $ri <br /> » » <br /> s..........._...._. .........._..__...... ....................... .................. .E................................. ............................. .............. <br /> w.=e..e.omm.v.x»w.ww.wn wexew>:roe.swe:<»sxm:ew.nma:as.eee w.xwwzwwrw.=�ww.rwr>M•xr rlwr=www..w <br /> eaWflltlti tlM YYfaYaellfeN AYdYZY�`.YW#,YN.YA)Y:q'.blunt#:A%#.'�N."M2':Y:#.^.Y:e`.Y^.w,,••>"#9.Y'.•.u••:'^Y ').: `Y, :?�Y e)Y>: Affi `A`.�pM NY%iOAYi AYAY1MikYNfM!"mM1MMi4pKt Al1�M <br /> m et nt� .mor gree rnn. �. <br /> 0— 11 <br />