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J SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISICN <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ffFACILITY SITE NAME FACILITY CONTACT NAME S/d�P�Z//J �• <br /> FACtI�� SS - StTE PHS f with AREA CODE <br /> CITY �+�,— [� STATE 2 PSE / / ofTANKS /�j�yl J/ <br /> / 771!re1 �/9 .a v��CP at SITE <br /> A APPLICANT/SILLINO NON: APPLICANT CONTACT NAME <br /> P <br /> P l✓£kz)T L'o•Y�^T SEL 66vTLES <br /> I NAILING ADDRESS /./ - APPLICANT PHONE S WITH AREA CODE <br /> A <br /> N CITY / • STATE IIP CODEAPPLICATION <br /> T `417j L"� CLOSUR NSTALLATION, etC. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) + 5100.00 <br /> I S <br /> V <br /> E TANK FEE = $50.00/TANK (prior to Jarwary 1,1991) 5170/TANK (after January 1, 1991) <br /> F d Tanks = _� 1986 1987 1988 1989 1990 1991 1992 1995 1994 1995 1996 <br /> A (mrltipty N by fee for <br /> C each year applicable) S <br /> i <br /> L STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> T it Tanks K $56.00 1986 through 19901991 through 1996 <br /> r (enter ea t and year) 5 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. M(a) <br /> L CLOSURE FEE • $53.00 per hour (3 hours minimum per TANK) f TANK(s) Z K $159.00 <br /> 0 X) � <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK t.D. !(s) e <br /> E TEMPORARY CLOSURE FEE • 2150.00 each TANK 4 TANK(s) _ K $150RECEIVE b --c— <br /> P PLAN CHECK (Install. Plan Review d Construction inspections) TANK I.D. S(a) rw 1191 <br /> L <br /> A PUBLIC HE I'TH 'il: t rc <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours mini mm per Facility) + 5424.00 mini& WIRpNMENTAL HEAL? })f7 <br /> R REPAIR FEE (workp(an review d construction Inspections) TANK I.D. S(a) <br /> E <br /> P TANK REPAIR FEE + 553.00 per hour (3 hours minimnVTANK) S TANK($) % $159.00 • f -G;2— <br /> A <br /> R PIPING REPAIR FEE • $53.00 per hour (3 hour mini mum per feellity • 2159.00) <br /> �Y O <br /> M TRANSFER FEE • 520.00 UNAUTHORIZED RELEASE EVALUATION • $53.00/hr S <br /> I <br /> S <br /> C CONSUL TATICN FEE + 553.00/hr SAMPLING INSPECTION FEE • $53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> TiiiwG—'1w.wGa.'TawiiwmTwaw•i�iw.`rwCiw�iwwaaTriwiirCaT'eGwiawAwaTSi iir�'ia .3iT3a'TCCsCwrGiwtw�•iwC>,Twaw;—...G w.:...i <br /> wi3Sw.ws�r�rwwGiw —wwi.�www+aTiwTw i+r+��sirawwGaw`waw..rrTwawawwwiGiri3Ga..Triesaim C+wwwfw <br /> r r mwrsrrwrrwwrarse rear r,ew irrrersawrr rrrerrsrrrr rr rr rrrwwr>.sr r ser rrw�rrrrrr r rwr r <br /> EN 23 032 (REV 6/4/91) It Pam 11 �,�� <br /> C , <br />