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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> Dan 'i Er-he-s -fom Ja�ie�D <br /> IFACILITY ADORES SITE PHONE # with AREA CODE <br /> I <br /> -7 D un h' Cl {+ b 2 -L4(oS- 5Z) <br /> T CITY STATE ZIP q C # of TANKS <br /> Y t.F�- 5p at <br /> A A L(CANT/BILLING NAM$= APPLICANTm N, <br /> P <br /> L - <br /> I MAILING ADDRESS 58 APPLICANT PHOfE# WITH-AREA CODE <br /> C <br /> A , o ` 80y <br /> T Ct./ STATE CO <br /> ZIP �E� TYPE of APPLICATION <br /> CCLOSURE, INSTALLATION, at <br /> TOTAL <br /> 0. <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I $ <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 �1 <br /> A (MLtiply # by fee for I O I $ —f D <br /> C each year applicable) <br /> I <br /> L STATE SURCNARGE = $56.00 each TANK (Due every 5 years) See California HSS Coda, Section 25287 <br /> 1 <br /> T # Tanks x 256.00 1986 through 1990 1991 through 1996 <br /> Y (enter amovlt and year) . � E C� <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) J <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X $159.00 f <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(S) _ X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review 8 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 minimus S <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) # TANK(s) X 5159.00 = f <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimus per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> 5 <br /> C FEE = $53.00/hr FEE = $53.00/hr FEE = E 53.00/hr <br /> TOTAL DUE E <br /> OFFICE USE ONLY <br /> ,u.. .....°»ro.:wrx.�:`..``Y�w?�:rxmrow:.a..w»...»m.x..:...x.:........,...,.,�.�..»v.....»I,�..,.... <br /> b't IS Tr' C`CDE AbErtl."RC�iU" CHEC`R`h/CA5N (C earn 'T '-L�`(3'fE"�1"'�""�`2�I�i <br /> =2y Eu o 2 9 321 $ ............................................._.......... <br /> . <br /> ow 7x n't9 rory 17f7A/9n1 fr P.lde 11 <br />