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SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OIVISICN <br /> UNOERCv0 STORAGE TANK PROGRAM FEE VCRKSHEET <br /> 1 <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> i� <br /> I , FACILITY ADDRESS SITE PHONE X with AREA CODE <br /> L. <br /> T CITY STATE ZIP CODE X of TANKS <br /> T C/)7— at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I NAILING ADDRESS APPLICANT PHONE X VITH'AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CCDE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1997 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior Co January 1, 1991) = 2100.00 / <br /> I /DD �() 2 '7 D <br /> V <br /> E TANK FEE 550.001TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F X Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (mutziply X ty fee for <br /> C each year applicable) ZCO (JQ .� s Ga <br /> ( U <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California M 3 S Code, Section 25297 <br /> T X Tarks q x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> ZZ S L <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-place) TANK I.D. X(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) X TANK(s)_ X 5159.00 = s <br /> 0 <br /> S <br /> U TE4PCRARY CLOSURE (A one-time permit, for review S inspections TANK I.D. X(a) <br /> R <br /> "e TE.4PCRARY CLOSURE FEE - 5150.00 each TANK X TANK(s) X 2150.00 = S <br /> P PLAN CHECK (Instal(. Plan Review S Construction Inspections) TANK I.D. X(s) <br /> L <br /> A <br /> N PUN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) = S424.00 mini mum S <br /> R REPAIR TANK 1.0. X(s) <br /> E <br /> P TANK REPAIR FEE - 553.00 per hour (3 hours minimum/TANK) X TANK(s) _ X 2159.00 S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = 553.00 per hour (3 hour minimum per facility - 2159.00) S <br /> RCCNSUITAi(CNS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> 2 <br /> G I FEE = $53.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S 3 <br /> OFFICE USE ONLY <br /> iUc75's��' LCt3"' `T'CC"`CCDylm)'IST GCDE.I•".UiCUNY�AC.D "'�I S A' I'�3C.D '3YATe' i5'JEd�'� r' 2. I�ssi <br /> i _..........._.._.. <br /> ......_.._............ .................... .5......_............._........ ........................... .. .._.........._.._._.._. ..............i <br /> u»: <br /> ii,/i Aei=Yi ial6.N A4J ffJaY3 'J"ii:Y .^..Y i.:•.':.i`J SJ=4 1e.11f y'JiYlf1 <br /> iw 21 nig iocv 1PrJ/.ignl Fr Pmee 11 <br />