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Of <br />SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES <br />ENVIRONMENTAL HEALTH <br />UNDERGROUND STORAGE <br />OIVISION <br />TANK PROGRAM - FEE WORKSHEET <br />'FACILITY SITE NAME <br />A <br />FACILITY CONTACT NAME <br />l�•t11 Jb`f (i <br />L <br />i i FACILITY ADDRESS <br />raS <br />3 <br />J L E <br />SIT PHON With AREA CODE <br />!' I <br />TCITY <br />—Q <br />Y STATE <br />ZIP CODE # of TANKS <br />a0 at SITE <br />A APPLICANT/BILLING NAME <br />P <br />P <br />APPLICANT CONTACT NAME <br />5 <br />` <br />Geis <br />I ILINC ADDRESSjo <br />C O/ / <br />APPLICANT PHONE N WITH AREA C E <br />N COT Y\I <br />T IC I' STATE ZIP CODE TYPE of APPLICATION <br />V <br />U �-zf�l910-71 <br />QOEU , INSTALLATION, etc. <br />O <br />ANNUAL FACILITY FEE (prior to January 1, 1991) = 5100.00 <br />A <br />C <br />TOTAL <br />T <br />1986 1987 1988 1989 1990 <br />I <br />V <br />$ <br />E TANK FEE = $50.00/TANK (prior to January 1,1991) <br />5170/TANK (after January 1, 1991) <br />F # Tanks 1986 1987 1988 1989 1990 <br />A (multiply # by fee for <br />1991 1992 1993 1994 1995 1996 <br />C each year applicable) <br />I <br />L STATE <br />O <br />i D OO <br />SURCHARGE = S56.00 each TANK (Due every 5 years) See <br />1 <br />California H & S Code, Section 25287 <br />T # Tanks_/ x $56.00 1986 through 1990 <br />Y (enter amount and year) <br />1991 through 1996 <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />L <br />CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) <br /># TANK(s) <br />G <br />X $159.00 <br />S <br />Q <br />S <br />U <br />R <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections <br />TANK I.D. #(s) <br />E <br />TEMPORARY CLOSURE FEE = S150.00 each TANK <br /># <br />TANK(s) X $150.00 = <br />$ <br />P <br />L <br />PLAN CHECK (Install. Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE - $53.00 per hour (8 hours minimum per facility) = $424.00 <br />minimum <br />S <br />REPAIR <br />TANK I.D. #(s) <br />R <br />E <br />TANK REPAIR FEE = S53.00 per hour (3 hours minimtmyTANK) <br /># TANK(s) <br />X $159.00 <br />$ <br />P <br />- <br />A <br />I <br />PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility) = $159.00 <br />R <br />MISCELLANEOUS EVALUATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br />S <br />(When applicable) <br />(When applicable) <br />FEE = S53.00/hr FEE = 553.00/hr <br />FEE = 553.00/hr <br />S <br />TOTAL DUE <br />$ 7 'a / OD <br />