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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY SITE NAME FACILITY CONTACT NAME <br /> C �Y S sou <br /> C <br /> I FACILITY ADDRESS SITE PHONE M with AREA CWE <br /> I5( 2l (7bf gs <br /> T CITY STATE ZIP CODE M of TANKS <br /> Y 52 <br /> at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P S <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE p WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1 1988 1 1989 1990 1991 1992 1993 1994 1995 1996 <br /> T <br /> I E <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F p Tanks z $SO.W 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply by fee for <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 8 SAFETY CWE, ®li cab i t ty) <br /> 1 <br /> T N Tanks x $56.00 1966 1987 1988 1989 1990 1991 99 1 1994 1995 1996 <br /> Y (enter ;Want and year) <br /> N C01 NT`( E <br /> PERMANENT CLOSURE (Removal or Closure-in-place) ENTIRO ENTAL HEAL <br /> C <br /> L CLOSURE FEE _ $90.00 each TANK k Tanks x $90.00 E <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $80.00 each TANK N Tanks x $90.00 E <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) S <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each SUBMISSION/RESUBMISSION k Tanks x $110.00 E <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minima; one hour to be paid on plan submittal) <br /> 1 <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> F U€P r r"SAP I ndr TVo"mor� mm"Am » i'e"`Amiir,.as x.xw»l6'mimmk'rrwg'71Prxa <br /> • oLuc it <br /> $ z <br /> .sMNMXrxwxr=wwAwwx«wx»iww�iw w .w�wwx...,wa.w,..,e..».»..»:»:e..z,.,,.w.x,.zo,:::;;d;, .......... .................. ...... <br /> oaaar.rAr...�w.lar,......ara......A��,...,avax.,m�xwmr.aw.......aw.ws,mw mraawmromro�,m .�w.�..rwsa.w......w.smw,.,ww,maw <br /> FH 23 032 (REV 6/901 ft Pane 11 <br />