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SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> IRONME.NTAL HEALTH DIVISION <br /> UNOERGjWTCRAG"c TANK PROGRAM - FEE WCRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT ,yA,ME <br /> �A A <br /> I FACILITY ADORES SITE PHONE X wi h AREA CCOE <br /> T CRY STATE ZIP CODE Y of TANKS <br /> Y 0376 at SITE �-- <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P 9 <br /> L <br /> L <br /> CMAILING =RESS D APPLICANT PHONE :WITH AREA CODE <br /> A S <br /> TCITY STATE ZIP CCA�� / TYPE of APPLICATION <br /> C/r� 6 CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1 1988 1 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 1100.00 <br /> 1 IDU /ov /ov Iw Oo S s p O <br /> E TANK FEE a 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 3 Tarks 1986 1987 1 1988 1 1989 1 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply 4 by fee for <br /> C each year applicable) loo <br /> I II <br /> L r STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25257 <br /> I <br /> T x Tarks �, X 356.00 1986 through 1950 1991 through 1996 �1 <br /> Y - (enter amount and year) Y <br /> PERMANERT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. ,Y(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimus per TANK) 9 TANK(s) X 3159.00 - S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 3 inspections TANK I.D. X(s) <br /> R <br /> 'e TEMPORARY CLOSURE FEE = 5150.00 each TANK B TANK(s) X $150.00 = 1 <br /> P PLAN CHECK (Install. Plan Review 3 Construction Inspections) TANK I.D. x(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 153.00 per hour (8 hours minim.m per Facility) = 1424.00 minimum S <br />' R REPAIRI TANK D. X(s) <br /> E <br /> P TANK REPAIR FEE = 553.00 per hour (3 hours minimum/TANK) X TANK(s) X 1159.00 = S <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW 3 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = 5159.00) $ <br /> N <br /> CONSULTATIONS UNAUTHORIZED RELEASEE EVALUATION SAMPLING INSPECTION <br /> l , <br /> S <br /> C FEE = 553.00/hr FEE = 153.00/hr FEE = 1 53.00/hr <br /> TOTAL CUE <br /> OFFICE USE ONLY <br />...._......................................................_............................................................................................................ <br /> ........................................ <br /> a tEPS s uCMP'R `CELL"CCO�c"""" DIST' uCOE .�L""";U�ICL))T RC40I Cnc Y <br />.....................1........................ ................. =._76.. � ? i ` <br />•___'�______•�_,....- - ..... ,..3.1..A.1.......... ........ a <br /> w JS nt7 rocv 17/7A/Onl fr • pine It <br />