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SAN JOIN COUNTY PUBLIC HEALTH SERVICE <br /> ENV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> U ERGRCUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME <br /> F FACILITY CONTACT NAME <br /> A <br /> C <br /> I FACILITY ADDRESS SITE PHONE Al with AREA CODE <br /> L <br /> 1 <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y <br /> at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # NITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> TI CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C [1!16 1987 1 1988 1 1989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I S <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 9 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X $159.00 5 <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 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 853.00 per hour (8 hours minimum per Facility) = 5424.00 minimum $ <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 minimum/TANK) # TANK(s) X $159.00 = S <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 = 553.00/hr FEE = E53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE E <br /> OFFICE USE ONLY <br /> .............."....................................................................................................................... <br /> .......... <br /> xe:ri.i�.se.w.w.we.xoea.x..»�.xeaexaezeee.�e:eeee ee.:eee.xa.:..»e.z..eeee.»o.w.eeexe.xe.xeee.xe.x..e.ze..eee.we.xeee..a:z::.:n:we:fa'oe:ine:neeeez'e:x'e:z:�eezro.»wes fo:.�e�esromeoe�ee:�::.xsrovro wes <br /> gSES *177T' 07SL1 C I', iFw" N"C `c c6 `a�a` ` c'.2 -` 7iomxxa+r <br /> s <br /> g <br /> 5 a <br /> s.......................... ........................ .................... ........................ .................................. .............................. ................................ ...........................................% <br /> xsarxaw awaoxmaarorfasam � � � �� � � �� � s � �Axa � axu ars amxars aqr xwrmmx ams aaasaurs anis attas <br /> EH 23 032 (REV 1/10/91) ft Pace 11 <br />