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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A18 ` I" K/ 4eW' <br /> C � <br /> I FACILITY ADDRESS _ SITE PHONE # with AREA CODE <br /> L Z . <br /> I <br /> T CITY � v, n STATE ZIPGCoo # of TANKS <br /> Y "I/_s�o,��1 Z- A /-3 at SITE / <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> ( ( c cmc C� <br /> I MA1L1 0 RESS APPLICANT PHONE # WITH AREA CODE <br /> C �JJ /6d D <br /> A <br /> N CITY S C' .1� TE ZIP CODE TYPE of APPLICATION <br /> TOC-�TBv� �-/5.'L( 3 CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 19891990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I E <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) $170/TANK (atter January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) <br /> I 5 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Cade, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> E <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X $159.00 = $ <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = 5 <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) = 5424.00 mini mm E <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimm/TANK) # TANK(s) X $159.00 = 5 <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = 5159.00) E <br /> M CONSU T+TIONS - UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FE = 553.00/hr Q� FEE = $53.00/hr FEE = E 53.00/hr <br /> TOTAL DUE E Q 6 <br /> OFFICE USE ONLY <br /> mams5i 'S7xa` -rff-ar r <br /> 77 <br /> ...._ . .. _ .. _ _ .. = w. = w = ..., .. ....... .............................. <br /> A%WMKiAai%lYAb49Aa1iAMt N'R4MXYARYLLI4ALAb'MYM2u' W1i RNtp�.p"aYi!'A.Ki'MTM WpYW mpY%K. WPAHMiY%KBVi AWlYA WA`IkYMW%MYHiAKYA NYNTiMY.AMKMY%i NtliAN[W <br /> EH 23 032 (REV 1/10/91) ft�,�„ ��, �� �Ja+-c�f' a /�c2P Paae 11 "'' <br />