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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICE <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> Gca,r✓ S. S � Yo9 <br /> 1 FACILITY ADDRESS SITE PHO �# with AREA CODE <br /> 1 :50 /U- � Q ao — 0// 9 <br /> T CITYE /O Gr� STATE 21P CODE # of TANKS <br /> Y _!F— � S at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L RD her f /74 ,?z& �`�ss1l 6���G.wriKeao <br /> 1 MAILING ADDRESS .t,a '1 APPLICAANNT PHONE # WITH_AREq CODE <br /> A I <br /> N CIT Y- STATE ZIP CODE TYPE of APPLICATION <br /> T \J � 'a 5 CLOSURE, INSTALLATION, etc. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> T <br /> I $ <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F # Tanks x $50.00 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 (see CA HEALTH 8 SAFETY CODE, Sec 25287 for applicability) <br /> I <br /> T # Tanks x $56.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> Y (enter ;;Duet and year) <br /> x <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> C <br /> L CLOSURE FEE = $90.00 each TANK # Tanks x $90.00 $ <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> R <br /> E TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks x $90.00 E <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) E <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each SUBMISSION/RESUBMISSION # Tanks x $110.00 E 3�/)� <br /> E 3-v <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 1 <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 530.00/hr FEE = $35.00/hr FEE = $35.00/hr E <br /> TOTAL DUE '33 <br /> OFFICE USE ONLY <br /> . .......................................... ............................................................................................................................................................................ <br /> owo z»xieee:6 zeii>ieeizieii:e.i.irzeeeozeowme...o=eeoe was zeeee=e.neo w.ow woe wee.w.wmee we.�e»zoeoe xee uxsx.e:w»www.ee.x.oz.o weaoezw woad�aoe zoww ze.n..zwee w..xepe.=erzeoo...e z.oe.xo=e.»uee�a <br /> www»woaaew�iaweiwa.woaeew»aa»awoi' owaaewe�oiwew»wwwewowa.waaasxe.weeo:vee»ri>ii»eeaze> vz»»iiww'eesoowr ww' ""YweJw»s»iemwieii:iiwew:w»+a <br /> xwwaattrwxwraa.swsxxpa�sfrasv_araazarat ., ��a�w���x�_�w�, �a���w, �� ���� � ��w,wr»a.��>� <br /> FH 23 032 (REV 6/901 It ...� Pnoe 11 ..r _ <br />