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SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANKPROGRAM - FEE wCRXSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NRIE <br /> F <br /> A <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L a-! O/ .C. �'K ' '4e 9 cl S - /O 77 <br /> I <br /> CITY STATE ZIP CODE # of TANKS / <br /> T j-tv C"') 5�S 1c>-' at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P � <br /> P <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> 4 CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATICN, etc. <br /> TOTAL <br /> A <br /> C k19111,6 1987 1988 1989 1990T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 o a0 5 <br /> V <br /> TANK FEE = 550.00/TAMK (prior to January 1,1991) 5170/TANK (after January 11 1991) <br /> -r 9Tanks = 1986 1987 1988 1989 1990 1991 1992 1995 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year appticablU � SO 5 00 <br /> t <br /> YU <br /> L STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> 1 <br /> T # Tanks / z S56.CO 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) 5 _ <br /> PERMANENT CLOSURE (Reamat or Authorized Closure-in-Ptace) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE a 553.00 per hour (3 hours minimm per TANK) # TANK(s)_ X S1 9.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> It <br /> E TE%PCRARY CLOSURE FEE a 5150.00 each TANK # TANK(s) _ X $150.00 = 5 <br /> P PLAN CHECK (Install. Plan Review d Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> 4 PLAN CHECK FEE - $53.00 per hour (8 hours minimm per Facility) a $424.00 minim S <br /> R REPAIR FEE (workplan review S construction inspections) TANK 1.0. #(s) <br /> E <br /> P TANK REPAIR FEE a $53.00 per hour (3 hours miniauNTANK) # TANK(s) X 5159.00 a $ <br /> A <br /> 1 <br /> R PIPING REPAIR FEE - $53.00 per hour (3 hour minioam per facility a $159.00) S <br /> M TRANSFER FEE a 520.00 UNAUIHCRIZED RELEASE EVALUATION a 553.00/hr S <br /> I <br /> S <br /> C I CONSULTATION FEE a 553.00/hr SAMPLING INSPECTION FEE a $53.00/hr S <br /> TOTAL DUE S pZ <br /> OFFICE USE ONLY _ 14_, <br /> C57 <br /> PFa <br /> ew ' .i�. Cs��nc ^ruAil a �cf�S'�d� i�ic Rca <br /> 3 75� czar o/ <br /> E4 Z3 032 (REV 4/8/911 ft Pax 11 <br />