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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> y✓✓✓ ENVIRONMENTAL HEALTH DIVISION <br /> RGROUND STORAGE TANK PROGRAM - FEE (1CRKSHE <br /> + 'FACILITY SITE NAME FACILITY CONTACT NAME <br /> .F ! <br /> A /o.e�. �G//E12/J/"1'e <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 00 oiv �� 9 c".Z3 - 7G B/ <br /> 1 <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y /f�.•f w 7f5 95336 OV a06� � <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P /7—Wu Ec0.0 y,�...s� A• 6-tioS -Tee; <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C - 02 <br /> ASTATE ZIP CODE TYPE of APPLICATION <br /> N CITY <br /> r .✓T6A .4 9533 G CLOSURE, INSTALLATION, etc. GLo0*crA.0 <br /> />7.9 � <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 5 <br /> V <br /> E TANK FEE $50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) $ <br /> 1 <br /> L STATE SURCHARGE - 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter arrant am year) <br /> E <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X $159.00 S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) _ X 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facility) = $424.00 minirtun S <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> F <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) # TANK(s) _ X $159.00 = 5 <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility - $159.00) 5 <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = $53.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> . ....................................................................... .. .................................................. <br /> ..............................................................................................�.._ <br /> er:e....... a......_..._.cp».:::i:...........= . .......»....r=.».......=rg y..�r:a..........».q.�»+..g a..,.=..t.»z.r,.e.z..tx.�......r.....r�w.z.,e.xe..» <br /> e <br /> -1� <br /> EH 23 032 (REV 1/10/91) it . Pace 11 <br />