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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME <br /> F FACILITY CONTACT NAME <br /> XON sG>rzvi�� ST--A(ON 7-33�0 AP�CF��E <br /> I FACILITY ADDRESS <br /> L -31Z$ ^,1'�J'RMIN I[., • SITE PHONE # With AREA CODE R'1'l N�nA • ' <br /> I <br /> T CITY fN -ii;HfQullvc <br /> Y STS:KTaN STATE ZIP CODE # of TANKS <br /> A�F/fA <br /> A APPU GA at SITE 0 S <br /> CANT/BILLING NAME ry S1QN <br /> FF(JW-Z'r Lee A!5i APPLICANT CONTACT NAME <br /> L1?d1 NU5EM4N <br /> I MAILING ADDRESS <br /> C - I - <br /> A K"MJP- I-FINLINls URU,E SU17� 12LJ APPLICANT PHONE # WITH AREA CODE <br /> N CITY <br /> T ARKS _ STATE ZIP CODE TYPE of APPLICATION 7b. <br /> GA 9'39 CLOSURE, INSTALLATION, e[T� 6w6v' p <br /> A <br /> C TOTAL <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 1986 1987 1988 1989 1990 <br /> I <br /> V <br /> E TANK FEE _ $50.00/TANK $ <br /> (prior to January 1,199 1) $170/TANK <br /> F # Tanks (after January 1, 1991) <br /> A (multiply #by fee for 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> C each year app(icable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK $ <br /> 1 (Due every 5 years <br /> See California H 8 S Code, Section 25287 <br /> T # Tanks x $56.00 <br /> Y (enter 1986 through 1990 <br /> embint and year) 1991 through 1996 <br /> E <br /> C Closure-in-Place)PERMANENT CLOSURE (Removat or Authorized TANK I.D. #(s) <br /> L CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) # TANK(s) <br /> 0 <br /> S X $159.00 = E <br /> U TEMPORARY CLOSURE (A one-time permit, <br /> R for revs eu/lnapec tions) TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK <br /> # TANK(s) % $150.00 = $ �p <br /> P PLAN CHECK (Install. Plan Review $ Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimum Per Facility) = $424.00 minimum <br /> E <br /> R REPAIR FEE (workpt an <br /> E inspections)review 8 construction inspeiTANK 1.0. #(s) <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours mini"AVTANK) <br /> A # TANK(s) <br /> I % 5159.00 = $ <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimus <br /> per facility = $159.00) <br /> E <br /> M CONSULTATIONS <br /> I UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C FEE = $53.00/hr <br /> FEE _ $53.00/hr <br /> FEE _ $ 53.00/hr <br /> OFFICE USE ONLY TOTAL DUE E <br /> • �OC�"C�1�k "'I3�"S�`C'C�)L�" ,�)'�('°�uC `m mx•::�rvree:;:sz::::»dwe:w::iwm:ie'a:»»z'aw.w..«... • . <br /> .. ........ <br /> ,arx su-nau =.._...=..•aee.=ue ez:a.=iiziizeAs `�/ s <br /> +lYmaltRtuRa: ..••www..«z..zeue=ai:eeiiiies:i`ei:..•.•..• a <br /> EH 23 032 (REV 1/10/911 fr aaxmvwa�u�xmxavu�<.,.-�--- _°°�•^^�-w--=���'�'�"••� <br />