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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES1— <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A S /d�/Z %lr//Clc�r✓ ffriiv//�Z- <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 3 <br /> T CITY /'/ S ATE ZIP CODE # of TANKS <br /> Y ��CCU� ,� 9S� at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <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 /> ANNUAL FACILITY FEE (prior to 1991) = $100 TOTAL <br /> A <br /> C /52 3—0 Z 1986 1987 1988 1989 1990 <br /> 9 <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) 5170/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) SU SZ 5Ci 50 $ Sd <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & SC, section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) _ // <br /> <J $ S co <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. # <br /> C <br /> L CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X $159.00 = $ <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.D. # <br /> R <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK # TANK(s) X $150.00 = $ <br /> P PLAN CHECK (install. Plan Review & Construction Inspections) TANK I.D. # <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours mini mm per facility) _ $424.00 mini mm $ <br /> REPAIR TANK 1.D. # <br /> R TANK REPAIR FEE _ $53.00 per hour (3 hours minimum/TANK) # TANK(s) _ X $53.00 = $ <br /> E <br /> P <br /> A MISCELLANEOUS EVALUATIONS <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION PIPING REPAIR REVIEW & CONSTRUCT. SAMPLING INSPECTION <br /> (when applicable) INSPECTIONS (3 hour mini mm) (when applicable) <br /> FEE _ $53.00/hr FEE _ $53.00/hr FEE _ $53.00/hr $ <br /> TOTAL DUE 8 <br /> OFFICE USE ONLY <br /> zeezu zzaieeaieeeeeieaai»zeiem z'ee zeoeez»we:e»».see:ieoeieeeeieeeeieeiieeeeeia:eieeeee»ee»zee zae•zee zxezeewzee zei z>w5»»eeeezee zeezewe zee iee:sues:ieew:iee:io'ae»ieieie>zeeeeze:�eweio'e:.wuro waevexuwzr rs <br /> ..... 3 $ g <br /> sas ms sex xax xaas ma x�tx mx xa xmm mx axax xec rsvu ms ,s xotx xxs fpm six mea aas xaa cmm xar � am x�a x�xrs aux��„�ar� axro xreu xava aas�xs xm rx�ras amx ms am amm am mx <br /> EH 23 032 (REV 12/26/90) ft Pace 11 <br />