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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISICN <br /> RGRCUND STORAGE TANK PROGRAM - FEE wCRKSHEER <br /> FACILITY SITE NAME <br /> F ^� FACILITY CONTACT NAME <br /> A J 6C L <br /> • i FACILITY ADDRESS r <br /> / •G<� SITE PHONE # with AREA CODE <br /> Y CITY /ST TE K ZIP <br /> CODE # of TANKS sa d at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P / . <br /> L <br /> I MAILING ADDRESS _ <br /> A �. Q AP LICAHT PHCAE # UI TH AREA CODE �'"4,)! <br /> Q O _ <br /> N CITY T <br /> Va T C /� ZIP CODE TY f APPLICATION <br /> ( OSUR INSTALLATION, etc. <br /> 2 Y42 <br /> A TOTAL <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 1986 1987 1988 1989 1990 <br /> I <br /> V S <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks 1986 1987 1988 <br /> A (mu(tip %by fee for 1989 1990 1991 1992 1993 1994 1995 1996 <br /> ly <br /> C each year applicable) <br /> I S <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 8 5 Code, Section 25287 <br /> 1 <br /> T # Tanks z $56.00 1986 through 1990 <br /> Y (enter anoint and year) 1991 through 1996 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 X 2159.00 CLOSURE FEE - S53.00 per hour (3 hours minimum per TANK) # TANK(s) 2 C lJ U <br /> 5 ✓ <br /> U TE4PORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review b Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> .N PLAN CHECK FEE - 253.00 per hour (8 hours minimum per Facility) = S424,00 minimum <br /> S <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = 253.00 per hour (3 hours minimum/TANK) # TANK(s) = S <br /> A __ X $159.00 <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facilit <br /> y = 2159.00) 5 <br /> M CONSULTATICNS UNAUTHORIZED RELEASE EVALUATION <br /> I SAMPLING INSPECTION <br /> S <br /> C FEE = S53.00/hr FEE = 553.00/hr <br /> FEE = S 53.00/hr <br /> OFFICE USE ONLY TOTAL DUE S L2 <br /> e.s. ....» ...: ..:.......e.::: ..._........................... <br /> a �.. c9r� 3R ffi?Wiwia'! <br /> s <br /> as.awaams vrrwaewrsr.eaeras .w...........•::...:iw:.�..r�:tf::.::»»::.:.:.::.::::»,::..»..:.•..:&.�..-..... .. .. _.s <br /> ++imra�saanrtss�ans�rwrxs„nwawwwssatsrarmaomsa�siwriws sarzesarw�nw�erw�r�n�s�,ws�ax`sw,assarawxm�aira maw=s <br /> EN 23 032 (REV 1/10/91) f[ <br /> • Pace 11 �^ ,� <br />