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�. _. w <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OIVISIOR <br /> UNOERGRCUND STORAGE TANK PROGRAM FEE UOAXtHEET <br /> LA <br /> LITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> LITY ADORES WE PHONE R ulth AREA CODE <br /> �� o� .�t�s 5-7 Od7 <br /> L STATE2iP CaGEof TANKS <br /> -.1 9�7 at Sit' <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT RAME <br /> P <br /> P <br /> L <br /> I HAILING ADDRESS APPLICANT PHONE 0 W11H-AREA CCOE <br /> c <br /> A <br /> N CITY STATE TIP COOS TYPE of APPLICATION <br /> t CLOSURE, INStALLAtION, eta. <br /> A TOTAL <br /> C 1986 1987 1988 1489 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) a 1100.00 <br /> I ! <br /> v <br /> E TANK FEE + 550.00/TANK (prior to January 1,1991) 5170/LANK (after JehUery 1, 1991) <br /> F s tanks a 1986 1987 1988 1989 1990 1991 1992 1993 1494 1995 1996 <br /> A (multiply Fry-fee for <br /> C each year app(teeble) ! <br /> I <br /> L STATE SURCHARGE A SS6.00 each TANK (Out every 3 year!) See CmIllornlA H A S Code, Stetson 25287 <br /> 1 <br /> T s Tanks R 156.00 1986 through 1990 1991 through 1996 <br /> Y (enter ;;-Ont and ylarf <br /> PERMANENT CLOSURE (Removal er Authorlied C(osure•In-P(Aee) TANK I.O. Ott) <br /> C <br /> L CLOSURE FEE a 153.00 per hour (3 hours minimua per 1ANK) If tANK(!) X !159.00 • S <br /> D — <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, ler review A inepeetton! tANK (.d. R(!) <br /> R <br /> E TEMPORARY CLOSURE FEE a 1150.00 each tANK /-Writ) X 5150.00 a ! <br /> P PLAN CHECK (tnetatl. Plan Revleu A Con/truetion Inspection!) fANK 1.0. R(!) <br /> L <br /> Al PAYMENT <br /> N PLAN CHECK FEE - 553.00 per hour (8 hour! mind" per ►eclllty) A 1:424.00 minletAd RaoS <br /> R REPAIR TANK C.O. /(!) 15 m <br /> E <br /> P TANK REPAIR FEE + 553.00 per hour (3 hours minlnWTARK) R LANK(!) <br /> A <br /> 1 LN <br /> R PIPING REPAIR REVIEW d CONSTRUCTION A 153.0d per hour (3 hour Mlml" per fselilty a 5159.00) ! <br /> N tousuLtAttal! UNAIRHORIZE0 RELEASE EVALUATION SAMPLING (NSPECtION <br /> 1 <br /> S <br /> C FEE = 553.00/hr FEE a 553.00/hr FEE a S 53.Od/hr <br /> TOTAL DUE <br /> OrFICE USE ONLY <br /> a i <br /> e /078 <br /> ws.v..>r ire rrsw'a warm nrxm ax�iva.. !L`YfSrt%�•? m!;3 mem a.'�c.`.Y9�DE a!"MmYa2!f:=�fbM1rm lam•'+. %�Yr�r Yr rrs srrlr mfr mrMaia <br />