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SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH Oill[SION <br /> UNDERGROUND STCRAGE TANK PROCAAM FEE WORKSHEET v <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A GeO, ! 'Sc l <br /> C <br /> I FACILITY ADDRESS / SITE PHONE ! with AREA CODE <br /> L / 705 /U , %3rc2c+ r-- <br /> I <br /> ST E zip CCOE X of TANKS <br /> Y CITY c Y`—cam Gq 9.Sa v/ at SITE <br /> A APPLICANT/BILLIINNGNT/AME APPLICANT CONTACT NAME <br /> P <br /> P Sr- G, �( /e.- <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE i WITH AREA CODE <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T S CLOSURE, IHSTALLAT IOM, etc. Pvt lc.Q�ie. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> 1 /OU /U '2ZdGrl hwD o0 <br /> E TANK FEE %50.00/TANK (prior to January 1,1991) 2170/TANK fatter January 1, - <br /> :A4: <br /> F 1 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 D '� �- <br /> A (multiply tl by fee for ( c _ /" ��9�`t L <br /> C each year applicable) Fl—mt/0012O'O CO 0 (a 50 (DSO f '/ho <br /> 1 <br /> L <br /> —STATE SURCHARGE 256.00 each TANK (Due every 5 years) Zee California HSS Code, Section 25287 <br /> I <br /> T Y Tanks z %56.00 1986 through 1990 1991 through 1996 <br /> T (enter mount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. Nis) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) N TANK(s)_ X $159.00 i <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review b inspections TANK I.D. M(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - 2150.00 each TANK f TANK(s) _ X (150.00 S <br /> P PLAN CHECK (Install. Plan Review d Construction Inspections) TANK I.O. $(s) <br /> L <br /> A <br /> N PUN CHECK FEE - 253.00 per hour (8 hours minimus per Facility) = tA2G.00 minimum $ <br /> R REPAIR TANK I.D. 4(s) <br /> E <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minimum/TANK) f TANX(s) _ X $159.00 f <br /> A <br /> I <br /> R PIPING REPAIR REVIEW L CONSTRUCTION - %53.00 per hour (3 hour minimum per facility - $159.00) f <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> Cl FEE _ %53.00/hr FEE = 553.00/hr FEE 2 53.00/hr <br /> TOTAL DUE % ,O <br /> OFFICE USE ONLY <br /> VET7S I I'r'mCt0(P m? s['CC Ts-F"'• rb15`T CODE ANC 1)IT It"O •CiiECF y/*ltSB:;��AGtA�'BY�� CepI�E�'m r 2 l�i""a <br /> t <br /> x577 G Cc'cs <br /> wwvw°wwi,:w drmam ss�>r i`nr^�A:m:tztsw�.-..mt wwl^s.- x`.�.ssm�.:^z.^.sT w:�zis�m�mar raw gas iss as�a�aamrirs <br /> rw 71 nco toew 1JAA/9211 Fr Paae ti <br />