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SAN JOAQUIN.000NTY PUBLIC HEALTH SERVICES sY <br /> ENVIRONMENTAL HEALTH DIVISION O rj <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET {� <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F pp <br /> A FOU 0.r -(2- <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> 1 <br /> STATE ZIP CODE a of TANKS <br /> Y CITY ^ C� q�3 at SITE �l <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> I MAILING ADDRESS ` APPLICANT PHONE R WITH AREA CODE <br /> PAYMENT <br /> $� <br /> N CITY TE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> SAN JOA IDI Ct) I'i TOTAL <br /> 1! <br /> 1 .r. <br /> A <br /> C ta����,�yy��t4TA1.01I b11151 7986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to Janwyl!40'1991) = 5100.00 <br /> S <br /> I <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F N Tanks = j_, 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply B by fee for <br /> C each year applicable) 1fl <br /> i <br /> L STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> I <br /> T K Tanks_ x $56.00 1906 through ,1990 1991 through 1996 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. M(a) V C� <br /> C <br /> L CLOSURE FEE - S53.00 per hour (3 hours minimum per TANK) B TANK(s)_ X $159.00 = f <br /> 0 <br /> 5 <br /> U TEMPORARY CLOSURE (A one-time permit, for review d inspections TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE $150.00 each TANK k TANK(s) _ % $150.00 S <br /> P PLAN CHECK (Install. Plan Review d Construction Inspections) TANK I.D. R(a) <br /> L <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (0 hours minimum per Facility) = 5424.00 minimum 5 <br /> R REPAIR TANK I.D. k(a) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) A TANK(s) _ X $159.00 = 5 <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW d CONSTRUCTION = $53.00 per hour (3 hour mini mm per facility - $159.00) f <br /> NCONSULTA71ONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C FEE = 553.00/hr FEE = S53.00/hr FEE = E 53.00/hr <br /> TOTAL DUE 5 (0,-1 <br /> S <br /> OFFICE USE ONLY ....... ..... r <br /> ••iw:::...,r r»uw r xme xa xaw mer wwa:w�w.w.e wrw.:m..v»:x<ee xn xiue xw:. <br /> rrsw r+r r„ww ..:;.::.w+•.t:.....Y. <br /> L ° " ITUTY"fm ° COr{1E i'I 'ST cCOE:-s i11 if RCG�f"rs'". . . C (CASH...• 'C B `Rt`°sA`;' '1'G`E'B""" dNI"f" " <br /> V S <br /> 5b'i ............ 1p1 �..3.. <br /> a.............._...... ..... sx«x x<a ewce..ne>:,,.:.:.. iew:ww�::r w'.rrw�iww:ww riiiw <br /> rwsrwr=�=wwwr=wrrrexnAe»ai m+ura waw wY:�ei:oe.:me waro:« <br /> fNIM YtM NailRlKiYaataleNOT.4YARY WYsY9S�FYR:Y AY2SSS32'�:.^.Y'.^...3'AY'^SY}9))�:.^"�1sX4:Y.:`:f CC::i^::Y I:.T:':Y i�Y J:Y••YCY G:Y'>YGtiAY RMY iIYLY A114�1WIMNlI�elYfYr/WMlli <br /> ru PL nsi /orw 17/2A/onl fr Pnon 11 <br />