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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A <br /> C <br /> 1 FACILITY ADDRESS- SITE PHONE # with AREA CODE <br /> T CITY STATE ZIP CODE if of TANKS <br /> Y �`.;,4 at SITE _ <br /> 31 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Ip` <br /> P U V 61 I�tl <br /> I MAILING ADDRESS - APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY 0 C T 111990 STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TP <br /> FACILITY FEE = $100.00 each p�i ' �. SEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> T <br /> I $ <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F # Tanks x 550.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) $ <br /> 1 <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 8 SAFETY CODE, Sec 25287 for applicability) <br /> I <br /> T ff Tanks x $56.00 1986 7987 1988 1989 1990 7991 1992 1993 1994 1995 1996 <br /> Y (enter arrant and year) <br /> E <br /> PERMANENT CLOSURE (Removal or Closure-(n-plate) <br /> C <br /> L CLOSURE FEE _ $90.00 each TANK # Tanks x $90.00 <br /> D <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 # Tanks x $90.00 $ <br /> P PLAN CHECK (I nstallati an or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) $ <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each SUBMISSION/RESUBMISSION # Tanks x $110.00 S <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <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 /> ................................................................................................................................................................................................................................................................ <br /> wwz»weoasww»wm wowa.w xw xw w0000 xu wm»xw ewm w»www zw xaewmwvs uaeeezwwww ww xw zx zxroxr zmw xww wasxa <br /> > Mr-1. <br /> TH 23 032 (REV 6/90) ft " Pane 11 <br />