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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES J ar)165 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME <br /> F FACILITY CONTACT NAME <br /> A <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> I <br /> I <br /> T CITY STATE ZIP CCOE # of TANKS <br /> Y <-� <br /> C at SITE <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N CITY STATE ZIP CODE TYPE Of APPLICATION <br /> T <br /> CLOSURE, INSTALLATION, etc. <br /> ;TANK <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> CILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> $ <br /> = 550.00/TANK (prior to January 1,1991) $170/TANK (after Jarwary 1, 1991) <br /> Z. 1986 1987 1988 1989 1990 1991 1992 1 1993 1994 1 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) <br /> I IC)C; e� I ICo $ G <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks Z x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) Z X $159.00 - g .� ( on <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 = $ <br /> P PLAN CHECK (Install. Plan Review & 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 minimum g <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimun/TANK) # TANK(s) X $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE _ $53.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE $ 4, <br /> OFFICE USE ONLY <br /> z=M grff?Toox».ioeix«"4ioeeiweeoz'eez'eez"aiesieie8eeeie»;z'eeiez'eoz>ieez'ee»isiee'eeeuncize'een'eow'e>iez'oiz'eeieeee:xw�"w>ee"zeezai:.<eiziee:ee>z'meiem'ee»eeemaewee6weezeiseziei>ne:z'ee'eewe6»ewxw'R"xawe"'iew"xe�"" ��' <br /> tl g <br /> a......... .. ... .... nV�GL....... . ...l..J.-� ........ C_ $ s <br /> weew»eeweexro' wmwae»weeawe»»»w»eeewexmwewe»»weeee iaew»ceases�'ieee'eeeeoo»izo»eoz'aez'aeooionei»ieiieeeieee'eeiaoeinioeezaeuawewexne wdeee wee oeeeee�eeo»>onaeeexaexiiieieoe»weefaooxeeeeiwezee�xeee x'aew� <br /> ars azar ars amts xa amax ma ass axas as att ata xwm sax aas amex ma amm atm amax arm xex aax arax rax �Dams ear sax xex ma xaax�ass axas xax amx am m�arm mmx ens ala ata ass <br /> EH 23 032 (REV 1/10/91) it Paae 11 <br />