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'1 <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ��jjpw YM <br /> SICR <br /> UNDERGROUND N STORAGE TANK HEALTHTAL IVI <br /> TANKROGRAHFEE WORKSHEET <br /> FACILITY SITE MAKE / rFACILITY CONTACT NAME c- .QN ••o <br /> F r, �, �i� vei,,L-c.� e,7,4, , us P <br /> 9 N 4 <br /> A o s . A r �P., C'� eu f44 , -. <br /> L FACILITY ADDRESSOrA SITE PHONE 0 with AREA CCO IIVT, <br /> L <br /> T CITY / SnTA�TE ZIP CODE 9 of TANKS /i'JSJO� <br /> Y S/V cAC/7/YI (� 9Sd-c73 at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P /`vr C it /!/C. /hGv� 7Ae,) <br /> L <br /> I NAILING ADDRESS APPLICANT PHONE S WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYP f APPLICATION <br /> T Gd �/ &. SI.R INSTALLATION, etc. <br /> TOTAL <br /> z <br /> C 1986 1987 1988 1 1989 1990 " <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 _ <br /> I lix 2W <br /> V <br /> TANK FEE S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> A # Tanksly fee for 1986 11987 1988 1989 1990 1991 1992 11993 1994 1995 11996 <br /> C each year applicable)? .� 6P <br /> I - OBD <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 3 S Cx'e, Section 25297 <br /> I <br /> T $ Tanks/ x $56.00 1986 through 1950 1991 through 1996 --- <br /> (enter amount and year) <br /> ,.Intoµ_, )/,-p/ S,a .U[7 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.D. 9(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) d TANK(s)_j— X 5159.00 <br /> 0 — <br /> S <br /> U TEMPORARY CLOSURE (A ore-time permit, for review/inspections) TANK I.D. x(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TAVK X TANK(s) X 5150.00 S <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. S(s) <br /> Ll <br /> A <br /> 4 PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Faci Lity) - 5424.00 minifnAm S <br /> R REPAIR FEE (workplan review S construction inspections) TANK I.D. a(s) <br /> P TAMK REPAIR FEE - $53.00 per hour (3 hours minimm/TANK) if TANK(s) X S159.00 : S <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour mini=m per facility - $159.00) 5 <br /> MTRANSFER FEE 520.00 UNAUTHORIZED RELEASE EVALUATION a S53.00/hr I S <br /> L I <br /> S <br /> C CONSULTATION FEE = 553.00/hr SAMDL ING INSPECTION FEE = 553.00/hr S <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> • /O/!� BE�u yo o/ 3 s 1-"711- 92 <br /> �•----- -II—III -----•• - --c,:•'�;°�G•�— .��_� ..��..,..�..,��;=>.>.�_� <br /> ::.,:.:.nss.:rss.i.�s�,'ssi.:,aaG:,i�..,:.s,:,:.,.�..:.:.,.�.,:.r..i•a-6.s s:,.i=:..=..ran r,..,.=r..s,. <br /> IN 23 032 (REV 4/8/911 ft Pa" 11 <br />