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�,. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES v <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> " JiM WN Je. <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L 01 <br /> I -Z9 <br /> T CITY STATE ZIP CODE I # of TANKS <br /> Ysmcrmj at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> SIA <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1 1987 1 1988 1989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I $ <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) $170/TANK (after 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 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) ACL <br /> C <br /> L CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) # TANK(s) Z X $159.00 = $ J7 00 <br /> 0 its <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 = $ <br /> P PLAN CHECK (InstaLL. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours mini mm per Facility) _ $424.00 mini mum $ <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 minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE _ $53.00/hr FEE _ $53.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE $ 7J o0 <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> g..24ss.... r <br /> .5.qCM 3 ... . . ...... . <br /> . . _321......... 09 <br /> . . $ .... ........ � �. K ~ <br /> . ..»» :; .... <br /> _._...,._,._ _ . _ <br /> EH 23 032 (REV 1/10/91) ft Pane 11 <br />