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SAN JOACUtN CCUNTY =178LIC HEALTH SERVICES Q <br /> ENVIRONMENTAL MEATH DIVISION CO 1 V <br /> UNOERGRCUND STORAGE TANK PROGRAM - FE: WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A Geo. ScA a /?r Se �R <br /> C <br /> I FACILITY ADDRESS SITE PHONE A with AREA CODE <br /> i7os �v , r3 —ocscl�cJc�� �� � - qy� -ssUv <br /> I <br /> T CITY ST E ZIP CODE $ of TANKS <br /> T 5-/-t7 Gr� y��7 G�1 9s,,)U/ at SITE <br /> A APPLICANT/BALING NAME APPLICANT CONTACT NAME <br /> P <br /> P Geo f. Sc G7 /er-- <br /> L <br /> I NAILING ADORES$ APPLICANT PHONE Y WITH AREA CODE <br /> �, c� , t33,< 131.2— <br /> A <br /> N CITY / STATE ZIP CODE TYPE of APPLICATION <br /> T .S ' 7 L `fir /s,,)Ji CLOSURE, INSTALLATION, etc. PotCi.Q/7C. <br /> TOTAL <br /> ;F1 <br /> 1986 1987 1988 1989 1990 <br /> ZFACtLITYFEE (Prior to;198,S <br /> ;19871988;1090849191?0 <br /> 0�7 Dov <br /> SO.00/TANK $170/TANK (after January 1, 1991) <br /> 1991 1992 1993 1996 1995 1996 <br /> A (multiply a by fee for <br /> C each year applfcable) C /C CU CO O �� (DR0 <br /> L STATE SURCHARGE + $56.00 each TANK (Due every 5 years) See California N S S Cade, Section 25287 <br /> 1 <br /> i .4 Tanks x $56.00 1986 1hrou91, )990 1991 through 1996 <br /> T (enter count and year) <br /> c - <br /> PERMANENT CLOSURE (Removal or Authorited Closure-in-Place) TANK I.O. $(s) <br /> C <br /> L CLOSURE FEE $53.00 per hour (3 hours mininsm per TANK) Z TANK(s)_ X $150.00 • $ <br /> 0 <br /> S <br /> U TEMPCRARY CLOSE (A one-time permit, for review d inspectiens TANK I.D. $(s) <br /> UR <br /> R <br /> E TEMPCRART CLOSURE FEE _ $150.00 each TANK R TANK(s) _ % $150.00 $ <br /> P PLAN CHECK (Irstall. Plan Review b Construction Inspections) TANK 1.0. xis) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimae per Facility) _ $426.00 miniffum t <br /> R REPAIR TANK 1.0. s(s) <br /> E <br /> P TANK REPAIR FEE + $53.00 per ham (3 hours minin"/TANK) ) TANK(s7 X $159.00 = f <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW $ CONSTRUCTION + $53.00 per hour (3 hour minium per facility + $159.00) $ <br /> 4 CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> C I FEE _ $55.00/hr FEE _ 553.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE F cat&0� <br /> OFFICE USE ONLY _ _ _ _—___.—..__—_---.—_-----_--------- <br /> :'iVE 7T70 r—C(W-1— aU <br /> CCC� WISiC'Ct1E AIRITCA:. C"nEC`LYIC.ISNi(c''l0"a'(' 3' t�iE•S""'S�z (�sa.:++: . <br /> e <br /> s <br /> a5'77 GEcr45�? O/ 3 3 $ - ----- ---------- --- <br /> e-_mac— <br /> 'arrrsisaii warmsssaa�ai-�s�sa:-Ats»a�IiGY-a:�tJ:.�:+=zx=::'.�:..��Yxsr�Cssyyraaa�as rss.rrarar ra=ar+rr <br /> rY 11 n1J ION 17/1A/IX11 Fe Paee h <br />