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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNOERGRQUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FFAC(LITYTE NAME FACILITY CONTACT NAME <br /> F /ASle/—CiDRESS SITE PHONE M with AREA CODE <br /> LIT L SI E 2IPCCOEX of TANKS <br /> YS�C� h L!� qsa D/ at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Geo , �. SG liJ u le r <br /> L <br /> 1 MAILING ADORE S APPLICANT PHONE X WITH AREA CODE <br /> 0, 6L),< /31-2 <br /> A <br /> T CITY ��l L� /^� STATE ZIpP C�J TYPE of APPLICATION ��C� t{- <br /> TV � !s � CLOSURE, INSTALLATION, etc. P', P <br /> TOTAL <br /> A <br /> C F//100 <br /> 1987 1988 1989Fle <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) 2100.00 <br /> 1 io aW DO <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 2170/TANK (after January 1, 1991) <br /> F B Tanks = _ 1986 1 1987 1 1988 1 1989 1 1990 1991 1 1992 1 1993 1 1996 1 1995 1 1996 <br /> A (multiply M by fee for <br /> C each year applicable) 0 /o 00 boa tool &W &jFQ 5 ;)/&o <br /> L STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> T x Tanks, x (56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount end year. <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. B(s) <br /> C <br /> L CLOSURE FEE - $53.00 per hour (3 hours minimum per TANK) B TANK(s)_ X 5159.00 f <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d Inspections TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK B TANK(s) _ X 5150.00 = 2 <br /> P PLAN CHECK (Install. Plan Review 6 Construction Inspections) TANK I.D. N(s) <br /> L <br /> A <br /> H PIAN CHECK FEE - 553.00 per hour (8 hours mini" per Facility) - $424.00 mini mm S <br /> R REPAIR TANK I.D. B(a) <br /> F <br /> PTANK REPAIR FEE = $53.00 per hour (3 hours minimm/TANK) A TANK(s) X 5159.00 = s <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW L CONSTRUCTION = 253.00 per hour (3 hour minimum per facility = $159.00) f <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE - 553.00/hr FEE = 553.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> X577 GECFS� <br /> :wi..................tia....�..Ol 3a3 . - ----._..........._......_...._....__........ <br /> .i <br /> 1R Y amr/saar mot YrlR eaeamas4a AY Y.)YYM�..Y 2YfRi:Y"' iLW�a`w.Y:�YY"A^.Y:".K'Y.':'S:'.`Y9fi:>.Y9«S.".::`.S.M..YG'S..VlY3Y:�Y""`YY/iMlW Tial!!new si aM aha R.'iYA <br /> rw Yt n\P roev 17/7A/o0a F, `� Paoe 11 6�e F15 <br /> 17 <br />