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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 fi 1�Ca STO 11-14 hit K E:"- <br /> C SITE PHONE # with AREA CODE <br /> I FACILITY ADDRESS (Zorl\J S3S?—�,c-70 <br /> L i ��� Ev'�t.iTr-I S1�f� E77 <br /> I STATE ZIP CODE # of TANKS <br /> Y CITY �h'��1 {? Cf! Wil' S3Z() at SITE 3 JCC]O© r��tl1.K�x`L <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P it <br /> P SE. <br /> L APPLICANT PHONE # WITH -AREA CODE <br /> I MAILING ADDRESS <br /> C 43 t W. N-TC �� �.�c7� 524- :A <br /> A STATE ZIP CODE TYPE of APPLICATION <br /> N CITY <br /> T M Q p€s, A � J3,3 0 CLOSURE, INSTALLATION, etc. C LAS i7 <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 $ <br /> I <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # -by fee for $ <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) $ <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-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 = 1 $ 4-77 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.D. #(s) <br /> R 1 # TANK($) X $150.00 ° $ <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK 1.0. #(S) <br /> L <br /> A $ <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) x $159.00 = <br /> A <br /> R PIPING REPAIR REVIEW && CONSTRUCTION = 553.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE _ $53.00/hr FEE _ $ 53.00/hr <br /> TOTAL 0UE $ QV <br /> OFFICE USE ONLY ................................. <br /> „.. <br /> ......................... .................,...,....... ..,.s:a xvr7 ro:. .. - r>s:s :u: .:.o-;:::•.rx:+:�-:.::+:•:<u:•xsra sea:aeNa:cm xsuo»w wea rooeoo waewwawro <br /> �MbO%600P 1006 MP706)DOp M0006 M06 7000%00007006)06016 MOP.LhYF:i084Y Fh3 K.. +v...`1\\�s'..v�.uwv�7•Y <br /> )rEPS' 41V 0e CI 1 13(457--CO)E` 'AMOL}0C`JD CnECC flIC1lSH :IRtVO'`$Y`" l c E cR I g <br /> °$ 4- �1 .C}G C 3 o i <br /> �•• M00 ktl00P M06 Mf�04?000:%A1:0.0.4A.<A:<6:-:W::{r};w+• :..;nu: .;.:yy KSKn .:iNi:i{SC4:<A:CK00 b06:Ao06%96 M06 bOWP MOP m0006�6b 1004061006 i400061P0Y 7006100906 k66 MOP <br /> fO4P>O0P M0000 M06 M0006 M06)00006 M06MW7944pP S •.. , ...:i:•3'y::4i RSS H..:Kif'.Y6.`..+.AY.7�6k1G FkLb55mAi AL�67D7F7�7S1�f 7'd�f%9F>3�1 RiLbY RA�SMfd <br />