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SAN JOACUTN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PRCGRAM - FEE UCRKSHEET <br /> FACILITT SITE NAME I FACILITY CONTACT RARE <br /> 1 FACILITY ADDRESS / SITE PHONE 0 with AREA CODE <br /> T CITY STATE ZIP CPE f of TANKS <br /> at SITE <br /> A APPLICANT/BILLING MW APPLICANT CONTACT NAME <br /> P 1-40 1 <br /> P <br /> n G <br /> � l�t Jt 5 -/ F,,-? ✓/W n <br /> I MAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> g E7Cc4 e-11' <br /> A <br /> N CITY STATE 2IP CODE yaw-orf-APPL <br /> CLOSURE,IINSTAI LATICN, etc. <br /> T /b2'v rYr✓✓ vl <br /> TOTAL � <br /> A <br /> 7986 1987 1 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> S <br /> IV <br /> TANK FEE SSG.DORANK (prior to January 7,1991) 5170/7ANK (after January 1, 7991) <br /> F 0 Tanks • 1986 11987 1988 1989 i 1990 1991 1992 1993 1 1994 1995A 1996 <br /> A (multiply X byb fee for <br /> C each year applicable) S <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H i S Code, Section 25297 <br /> T 0 Tanks x $56.00 7986 through 7990 7991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> C TANKI <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) .D. O(a) <br /> / <br /> L CLOSURE FEE $53.00 per hour (3 hours minimum per TANK) f TANK(s)—L X 5759.00 = S <br /> 0 <br /> S <br /> U TE74P(RUT CLOSURE (A one-time permit, for review/inspections) TANK I.D. O(a) <br /> R <br /> ETEMPORARY CLOSURE FEE a 5150.00 each TANK 0 TANK(s) X 5150.00 = S <br /> PPLAN CHECK (Install. Plan Review L Construction Inspections) I TANK I.D. 0(s) <br /> L <br /> A <br /> H PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 mini mrlo S <br /> R REPAIR FEE (workplan review S construction inspections) TANK I.D. O(s) <br /> E <br /> P TANK REPAIR FEE - 553.00 per hour (3 hours miniaun/TANK) I 0 TANK(s) _ X $159.00 S <br /> A <br /> 1 <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minis per facility - 5159.00) S <br /> N TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S53.D0/hr I I S <br /> I <br /> 5 <br /> CCONSUl7AT1ON FEE = 553.00/hr SAMPLING INSPECTION FEE - 253.00/hr I I S <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> sw�i. LIc ^D�'� r���' aCr wnc �jas v�e.�b��rracaC�°■ i <br /> ■ _ �- 1 a <br /> 5 <br /> f_ <br /> rrr■rsra rr�isirsrsrrr■rsrsrrsrr�r rara=�airrars r�aarsrsaia�rarrr■rrr <br />