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SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> GROUND STORAGE TANK PROGRAM FEE WCRKSHEE0 <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A <br /> I FACILITY ADDRESS SITE PHONE #`w1Ch AREA CODE <br /> 3 -S, S-1r,C- <br /> T CITY c STATE ZIP CODE l �,*1 # of TANKS <br /> Y �(•� 7J `( at SITE <br /> A APPLICANTBILL CLING�NMEE y ►/��/(� �// ///J APPLICANT CONTACT NAME <br /> I MAILING ADORESS� APPLICANT PHONE # WITH4REA CODE <br /> C <br /> A <br /> N CITY _ STATE ZIP CODE TYPE of APPLICATION ✓'Q 4 i;5 f-4 <br /> T � CLOSURE, INSTALLATION, etc. Cl <br /> V <br /> A TOTAL <br /> C 1986 19871988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991). = $100.00 <br /> I too loo loo I lvo /QO $ Z <br /> v j <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/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 _ 15011-7 <br /> C each year applicable) <br /> f 5Q 5(i .S(� ,jQ !Q 1-7Q 5[y� <br /> c <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks_L_ 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) _ <br /> S 5 5 ;- <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 minimum per TANK) # TANK(s)_ X 5159.00 S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = S424.00 minimum S <br /> R REPAIR TANK 1.0. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 853.00/hr FEE = $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY - <br /> .......................................................................................................................................................... <br /> »»»,..�..o..owo:.w.:..w.....<we. x ..tee k .. ..... .. ............ .................. . .... <br /> :` vx a;zsxsaVi <br /> $ c?S s CCMP1°xtf "`C'OC"CCDt DIST CODE UICUl7Y RC,U """i C.icC,C .)CASiiiZ 14 8Y ' t'"CTWCcl'iE 'r 1Y(i+y s » <br /> a <br /> $ S s <br /> w;::;.:y.:«.e:.."..«�:ae xee,.z................»....o......».e.eee..»,.. <br /> ATi Abi AldLfAY ASW Aa�RWiWfAS5AHYAAYSOYA A>dxLYS AN�:AY:SJ iAY:::t`w':AY aY$A'�^SS.L:#:L]Y•..••i:•^::�.:N'::,^;i.Y:�:�..'::.^,YiA.:rAY 9.SDYT.Ji..3 iuH 2:::Y.'.Y63 AVtMYR]i YliA>W=AI A'NtYR6fA#RSWWi AYi <br /> CV JZ nib /DCV 17/PAignl it • Pna n. 1 <br />