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SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 10 <br /> r U RGRCUND STORAGE TA11K PROGRAM - FEE VORX SHEET <br /> FACILITY SITE NAME <br /> F FACILITY CONTACT NAME <br /> C 40.r- 1. <br /> a <br /> I FACILITY i_Y ADDRESSSITE PHONE 0 with AREA CODE <br /> 7Fi] C� a 8g v <br /> T CITY v�-�'�/ ��E ZIP CCOE a of TANKS <br /> Y S � at SIZE / <br /> AAPPL!CANT/BALING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> 1 MA1lIHG ADDRESS <br /> C APPLICANT PHONE X WITH AREA CODE <br /> A <br /> N CITY <br /> i STATE ZIP CCOE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 1986 1987 1988 1989 1990 <br /> 1 <br /> v J)DD PJC?apl? s <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) 3170/TANK (after January 1, 1991) <br /> F Tanks = <br /> A (multiply tl by lee for <br /> 198995 6 1987 1988 1989 1990 1991 1992 1993 1994 11996 <br /> C each year applfca6l e) !0 <br /> 0 <br /> 5-ko <br /> L STATE SURCHARGE $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> t <br /> TA Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 7 5 <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. k(s) <br /> L CLOSURE FEE - $53.00 per hour (3 hours minimum per TANK) 2 TANK(s) % $159.00 = S <br /> 0 -- <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d inspections TANK I.D, 0(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - S150.00 each TANK 0 TANK(s) X 5150.00 = 5 <br /> [PPLAN CHECK (lrss tall. Plan Review d ConstD. 7(s) <br /> N CHECK FEE - $53.00 per hour (B hours minimum per Facility) = $424.00 minimum S <br /> R REPAIR TANK I.D. ATM <br /> E <br /> P TANK REPAIR FEE $53.00 per hour (3 hours minimum/TANK) Al TANK(s) % 1159.00 5 <br /> A -- <br /> 1 <br /> R PIPING REPAIR REVIEW d CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = 5159.00) 5 <br /> N CONSULTATIONS UNAUTHORIZED <br /> 1 RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C FEE - 553.00/hr FEE 553.00/hr FEE 5 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> :.::: :.s... .... <br /> � �� �COlIp�� `SOC CC{1�F�"AblST CCOE' ANCUIIT RC+D. .• -�CNEC:C'J/CASN� R CLO"AY""' :�,{Tc-�Ce(T/EB'y'�E71'II�s y": ' <br /> ' S <br /> rrrrvas.aarairsa+lssAm¢s>xxsm:.,„.�;�:nors:m^t::-:_...:.s»`s.-"ssa:.^�>:->:cz •.::;:�M�::a: - ...._ ....._._...._.._..........�.�^_.��� <br /> . u:.;.:3Cf':=3AD 0•.`SS JJ da YtDitM/l�afa]�=M 09aiY Al <br /> cw 11 nn leev t717A/eNl it <br /> Pnm. �1 <br />