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�i <br /> SAN JLIAOUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> f UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> FO�DANK <br /> TACT NAME <br /> FACILITY SITE NAME <br /> A L A P-1 G S"Ti's i`J t✓�1'�1Z K Ems` <br /> C # with AREA CODE <br /> I FACILITY ADDRESS $j -- <br /> LI STATE ZIPof TANKST cITY +CqSITE 700l_1.(JONTACT NAMEA APPLICANT/BILLING NAME �� �>�PsEMJQPL HONE # WITH•AREA CODE <br /> I MAILING ADDRESS S2�}-� �1(�S3 <br /> 4-3 i cu. <br /> A STATE ZIP CODE TYPE of APPLICATION <br /> N CITY O0 7 �^R � eJ�J'3� CLOSURE, INSTALLATION, etc. ��–U, <br /> T <br /> TOTAL <br /> A 1986 19$7 1488 1989 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 $ <br /> I 1991) <br /> V 5170/TANK (after January 1, <br /> E TANK FEE = $50.00/TANK (prior to 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 /> iears) See California H & S Code, Section 25287 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 y <br /> I198b through 7990 1991 through 1996 <br /> T # Tanks x $56.00 5 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal TANK I.D. #(s)or Authorized Closure-in-Place) $ <br /> J X '5159.00 = — <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /> 0 <br /> S permit, for review & inspections TANK I.D. #(5) <br /> U TEMPORARY CLOSURE (A one-time <br /> R # TANK(s) X $150.00 <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A $424.00 minimum <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ <br /> TANK I.D. #(s) <br /> R REPAIR S <br /> E # TANK(s) <br /> X $159.00 = <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /> A $ <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S FEE = 553.00/hr FEE _ $ 53.00/hr <br /> C FEE = $53.00/hroU <br /> TOTAL DUE $ L4-�� <br /> OFE"FI°CE' US"E ONLY %TCO:I.f.E.'.)€:iY Ahlll11TA' VI) <br /> ^j . :x <br /> '� i I�y <br /> 'M-:11.1 4 ,j : ` ` C % c+ ,xa�£ � E <br /> RCK' <br /> trvlt <br /> ar M04%W2 s a•:<:io>r ..•,.Eris'"«%ai!<s;':;::c% ;.y.ltrrryx+4xa.;.! 'T. A M#RYdAW <br /> c^rr <br /> ,yRpp x40L�iM�`AwiP MM1�'M RW IMr XWM kO!%Ovb?�16 YM�:idO;4L+A>Y:O:V+4 , ..,....�...... <br /> 'DD�f)761�91Y� 51�A1�7��DL iD��.�.YN.Y T�iS�HilijSrv$j'+r�. O•:.nG �� _... . <br />