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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION A <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET 4 L <br /> FACILITY SITE NAME / <br /> F FACILITY CONTACT NAME <br /> I Cp fYh s `��/ <br /> I FACILITY ADDRESS PM �)✓.l7 FH pC1e ✓O NOf <br /> LI )'-4 R SITE PHONE # with AREA <br /> 1 <br /> I CITY q�/yySFUNJr <br /> Y STATE ZIP CODE # of TANKS No S <br /> at SITE /i'�p/� <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> L J <br /> 71 Gov (ppli '^ <br /> 1 MAILING ADDRESS <br /> C I I APPL CANT PHONE # WITH AREA CODE <br /> N CITY <br /> And <br /> STATE ZIP CODE 1YPE of APPLICATION <br /> 7 C1 CA gLHOO-4- CLOSURE, INSTALLATION, etc. �� ( <br /> A <br /> C TOTAL f <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 1987 1988 1989 1990 <br /> I <br /> V <br /> S EJ <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) E170/TANK W <br /> (after January 1, 1991) t <br /> F # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 <br /> A melt a I 1995 1996 fee <br /> efor �-- <br /> C each year ear applicable) <br /> IE ■s <br /> L STATE SURCHARGE _ $56.00 each TANK <br /> I (Due every 5 years) See California H d S Code, Section 25287 <br /> T # Tanks x $56.00 1986 through 1990 <br /> Y (enter amount and year) 1991 through 1996 <br /> E <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L CLOSURE FEE - E53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = <br /> ° TANs DE <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK <br /> # TANK(s) X E150.00 = S <br /> P PLAN CHECK (Instal(. Plan Review 6 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 mini mm <br /> S <br /> R REPAIR <br /> TANK I.D. #(s) <br /> P TANK REPAIR FEE = E53.00 per hour (3 hours minimum/TANK) # TANK(s) <br /> �_ X E159.00 <br /> A ✓ LJ <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour mini mm per facility = $159.00) <br /> _ E <br /> M CONSULTATIONS <br /> I UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C FEE = $53.00/hr FEE = E53.00/hr <br /> IEE = E 53.00/hr <br /> 701AL DUE S 131 <br /> OFFICE USE ONLY <br /> ............................... <br /> may mnaaa�raerwrs�m�x�rcwx -••»•"^•• ................•........ ... <br /> mxsmTxa�saas»yxx. •e:..«exwz�a««.»r;p;::ro::..:.%::araev.«ea%:::»»:..,.t,;:a:...... _ <br /> �y .>,a.M�^...tSu;•rn.�„xaxx:zs'�:�",,.:rxs<..;..;.,:xx:s«t«�-s:�i..a«tt�xx;....sc�::�ar'a�`�.�....................... ...._.x <br /> -.. ,• ^„ -^-„ •�.+<,rv.. <. wn asaaxaraoawrrxaxreran:wwasms <br />