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SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRCNMkNTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> iACILITY SITE NAME FACILITY CONTACT NAME <br /> ti (�l <br /> IFACILITY ADDRESS <br /> L l O� � PHONE tl with AREA CODE <br /> 5 %T 17J� <br /> t T CITYn !� Si T ZIP CODE f of TANKS <br /> Y Jr�f 7lt/ C� S at SITE 2 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> ` <br /> I NAILING ADDRESS ) APPLICANT PHONE,9 WITH -AREA CODE <br /> N CITY ,.y)� STATE ZIP CODE TYPE of APPLICATION <br /> T / Sto S3 CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 7986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FE_ (Prior to January 1, 1991) • $100.00 <br /> I S <br /> V <br /> E TANK FEE • $50.00/TANK (prior to January 1,1991) f170/TANK (after January 1, 1991) <br /> F f Tanks • 'Z 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply 0 by fee for <br /> C each year applicabla) S 3 <br /> I <br /> L STATE SURCHARGE a $56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> 1 <br /> T # Tanks z $56.00 1986 through 19901991 through 1996 <br /> T (enter amount and year) <br /> f e�Z <br /> PERMANENT CLOSURE (Removal or Authorized C(osure-in-Placa) TANK 1.0. t(s) <br /> C <br /> L CLOSURE FEE • $53.00 per hour (3 hours minimum per TANK) 7 TANK(s)_ X $159.00 = f <br /> 0 <br /> S <br /> U TEMPCRARY CLOSURE (A one-time permit, for review d inspections TANK I.O. s(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • $150.00 each TANK 9-TANK(s) _ X $150.00 • S <br /> P PLAN CHECK (Install. Plan Review d Construction Inspections) TANK I.O. 7(s) <br /> L <br /> A TG�N PLAN CHECK FEE $53.00 per hour (8 hours minimum per Facil lty) a f424.00 mini mum f <br /> R REPAIRTANK I.D. 9(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimuNTANK) 4 TANK($) _ X $159.00 • S <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW d CONSTRUCTION $53.00 per hour (3 hour minimum per facility = $159.00) f <br /> M CONSULTATIONS - UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE • $53.00/hr FEE • S53.00/hr T FEE - S 53.00/he <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> >�as , �clRscEa1 "li"s�-c'ca '� Af(cuNfc?o c+E? .icAs °—"ri aY"—d`d �-(CE3" :�;At s ; <br /> ' ' <br /> n �.� »w. v«.w.v.=...:wwn.....7A�:' .,•a.•::. :: �/`avairaitr.erwa.errawaes <br /> i•m rrrror�a[amm:o usmsaz.:.:sa9am.K xiawi^..—Y�:;SJPtisSisltisx3avNax�m�iaNmmis3xn�c++w <br />