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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A <br /> I <br /> FACILITY ADDRESS SITE PHONE kwith AREA CODE <br /> �/� <br /> I S7 <br /> T CITY STATE ZIP CODE 4 <br /> LN o(�ANKS / <br /> Y 2t C�" at SITE G � C)) "Z rjyo� <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P ll <br /> CS> F2 — rz rc l ass/c( <br /> CNAILING ADDRESS APPLICANT PHONE N WITH AREA CODE <br /> Af-7—o-7) <br /> N CITY STATE ZIP CODE TYP of APPLICATION <br /> I �� Cid} Z CLOSURE, INSTALLATION, etc, OP, ov <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) a $100.00 <br /> I f <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) %170/TANK (after January 1, 1991) <br /> F N Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 19^>5 1996 <br /> A (multiply ir6y—Yfee for S <br /> C each year apps lcable) % <br /> I <br /> LSTATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H b S Codr., Section 25287 <br /> T ! Tanks X $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter errant and year) — <br /> $ <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 minims per TANK) N TANK(s)_ X 1159.00 Rr <br /> 0 <br /> f <br /> V TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. !(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK N TANK(s) X 1150.00 S <br /> PI PLAN CHECK (Install. Plan Review 6 Construction Inspections) TANK I.D. !(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minims per Facility) = $424.00 minims % <br /> R REPAIR FEE (workplan review Z construction inspectl ons) TANK I.D. !(s) <br /> P1 TANK REPAIR FEE = 153.00 per hour (3 hours minimm/TANK) N TANK(s) _ X 1159.00 = f <br /> URI <br /> PIPING REPAIR FEE _ (53.00 per hour 0 hour minimus per facility = 1159.00) S <br /> N TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = %53.00/hr f <br /> I <br /> e CONSULTATION FEE s $53.00/hr SAMPLING INSPECTION FEE ■ $53.00/hr S <br /> TOTAL DUE f <br /> LEW I E �1=6x1�1wrr kr(11�7ra Irffri fflifl:i1W srA � f ET�W��WWeu Wmrir6 ' E <br /> .fi �/.. ---. . _ .. . . .. ... men... / .. . . <br /> ll WIPINflWVWP PWfIW11iIVWiVWiP11WIN18®1BW21VIIVflW11111N:16Y6HB1aVVa0riWNriNVBi1N'e1131iN161ep11W.IW11VuLiiil:(f111iWIWi1WW4WW'u'WIIIWVIiWVtiiililiWliWWW WVI"""'^`V50i <br /> EH 23 032 (Revised 4/8/91) Page 11 �� I f.r'� � '✓ <br /> 0 <br />