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la(�I�s <br /> . • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 94-`-418 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> a <br /> il FACILITY ADDRESS P SITE PHONE # with AREA CODE <br /> EIVED <br /> T CITY �. . , r6T1TE 4 CODE # of TANKS <br /> lJ at SITE <br /> A APPLICANT//--BILLING NAME S t', G�'7.0 P ICANT CONTACT NAME <br /> P PUBLIC HEALTH - <br /> SI <br /> P ) ENVIRONMENTAL HLAL •J <br /> L <br /> I MAILING ADDRESS - APPLICANT PHONE # WITH AREA CODE <br /> C L <br /> A ) <br /> N CITY STATE ZIP CODEC I T DE 6�ADPLI CATION <br /> T n .� . -t-t -� C_ c.. -Z LOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1 1988 1 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> 1 g <br /> V <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = Z 1986 1 1987 1 1988 1 1989 1 1990 1991 1 1992 1993 1994 1 1995 1996 <br /> A (multiply # by fee for ^ <br /> C each year applicable) I0W I g <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> I <br /> T # Tanks Z x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter arrant and year) <br /> C Clo <br /> PERMANENT CLOSURE (Removal or Authorized sure-in-Place) TANK I.D. #(s) <br /> L CLOSURE FEE - $53.00 per hour (3 hours mini num per TANK) # TANK(s) X $159.00 <br /> $ ( O° <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = E <br /> P PLAN CHECK (Insta(L. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 mini5 <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours mininum/TANK) # TANK(s) X $159.00 = 5 <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour mini mm per facility = $159.00) E <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE = $53.00/hr FEE = E 53.00/hr <br /> TOTAL DUE E <br /> OFFICE USE ONLY <br /> ............................................................................ . ...... . ............. . ....... ........ . ...... ..... <br /> z»i o....... .... ... ........ . <br /> a e=..:=a.x w o: <br /> SSaw cQS' Ct3 °fs�'"c " D N"87Naro.�,,�r,w t°"�� <br /> 3.4 ...6.i <br /> ............................ ........................ ............... <br /> EH 23 032 (REV 1/10/91) ft Pace 11 <br />