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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OI'/ISION <br /> UNOERGRCUHO STORAGE TA11K PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME <br /> F FACILITY CONTACT NAME <br /> PAYMENT <br /> I FACILITY ADDRESS <br /> L SITE PHONE H with A A CODE <br /> I 3a d V OCT 0 2 1992 <br /> T CITY STATE ZIP CODE x of TANSAN JOAQUIN COUNTY <br /> T <br /> �U D at SITI+UBLIC HEALTH SERVICES <br /> A APPLICANT/BILLING NAMEPf <br /> P APPLICANT CO AC AME <br /> P <br /> L F dF EGf�An(vre �rA <br /> I MAILING ADDRESS AP LICAN PHONE X WITH AREA C005 <br /> A (01 GGG1 -z6 <br /> N CITY <br /> STATE ZIP CCOE IC.T.PE of APPLICATIONSURE, INS TALLAiION, etc. <br /> A TOTAL <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 )986 1987 1988 1989 1990 <br /> I <br /> V IOU 2'co �') <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F9 Tanks = ( 1986 1987 <br /> A 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> (multiply 11 byby fee for <br /> C each year applicable) v 50 /-';V /DO 3yU <br /> 5 /Z> FrU <br /> L STATE SURCHARGE = $56.00 each TANK (Owe every 5 years) See California HSS Code, Section 25287 <br /> 1 <br /> T F Tanks x 156.00 1986 through 1990 1991 through 1996 <br /> T (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. 9(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) 0 TANK(s)�_ X $159.00 = S <br /> 0 <br /> 5 <br /> U TEMPORARY CLOSURE (A one-time permit, for review S inspections <br /> R TANK I.D. p(s) <br /> E TEMPORARY CLOSURE FEE - 5150.00 each TANK k TANK(s) X 5150.00 = <br /> S <br /> P PLAN CHECK (Install. Plan Review S Construction Inspections) TANK 1.0. A'(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum <br /> f <br /> R REPAIR <br /> E TANK I.D. 9(s) <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimlmVTANK) ,Y TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW S CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = 5159.00) S <br /> M CONSULTATIONS UNAUTHORIZEO RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE S 53.00/hr <br /> OFFICE.USE ONLY TOTAL DUE S <br /> ....,.�.�...._ ... <br /> ��q <br /> _.�....�.�. .. <br /> i�SuE cam'S ' cod 'OC"CO�7E�o��'•b1 ST CCOE ' Y A ICUIIT*RC�U Y "CnE Cf.0 �l/C,IS�"'" -RC`iD r81'' M'Tc"k CEI/Er'PrIT ('Y ,s' <br /> ' -- <br /> ru :::_...... .._.................... ....o. Z <br /> .. ._. .............a....z.....o.....�.... <br /> �....3.....i <br /> �« <br /> n n17 .ow vnaom n P,e„ . Ar..a <br /> , <br />