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SAN JOACUIN COUNTY PUBLIC HEALTH SERVIC0 <br /> ENVIRCHMEENTAL HEALTH DIVISION <br /> UN,^._:3C;ZCuNO STORAGE TANK PROGRAM FE= WCRKSHEET <br /> FACYLITT SITE NAME FACILITY CONTACT NAME <br /> C <br /> 1 FACILITY ADDRE,S_4— SITE PHONE � with AREA CODE <br /> I CITYSTATE ZIP CODE R of TANKS <br /> T at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> I MAILING ADDRESS '� APPLICAII TM7E 1 WITH AREA CODE <br /> CC <br /> Ej <br /> N CITY STAT€ IP'C06EI�'t 1I TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> + ES TOTAL <br /> A <br /> C 1986 x1987 1988 1 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> I S <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 0 Tanks = 1986 1987 1988 + 1989 11990 1991 11992 1993 11994 11995 1 1996 <br /> A (multiply K 5y fee for + <br /> C each year applicable) �� I y 0 -O G1 X16 I S ?c <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Cade, Section 25287 <br /> I <br /> T M Tames x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 4d 5 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) I TANK I.D. »(S) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) TANK(s) X 5159.00 = S <br /> O <br /> S I <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspect,ions) ! TANK Y.D. #(s) <br /> TEMPORARY CLOSURE FEE = S150.00 each TANK III X TANK(s) x $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) I TANK I.D. �'(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 353.00 per hour (8 hours minimum per Facility) = $424.00 minimum S <br /> R I, REPAIR FEE (workplan review 8 construction inspections) I TANK I.D. R(s) <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) R TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53,00 per hour (3 hour minimum per facility = S159,00) S <br /> M TRANSFER FEE = $20,00 I 1UNAUTHOR12ED RELEASE EVALUATION = S53,00/hr I S <br /> S I I <br /> CI C:NSULTATICN FEE 553.00/hr I ( SAMPLING INSPECTION FEE = $53.00/hr I S <br /> roraL DUE s G, - <br /> OFFICE USE ONLY <br /> ass- -r�`ro:..ws:r:+ ... ., ,,,,a,,, „rte ��.. ...��r:• . :;:z:::a u,., :�s� szT;-'�--,"', - :�crc�c <br /> =Mp K cI LSC C U_ i'S CO <br /> CE I Cuii C`+1) CnE'_ ASr; r�_:Jou alp Dr i c 1zACV- <br /> �_ <br /> z <br /> EH 23 012 (RE'Jft Pace 11 <br />