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SAN JOAQUIN COUNTY PUBLIC HEALTH $ERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WCRKSHEET <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAME <br /> F ��A SITE PHONE # with AREA CCOE <br /> C <br /> 1FAClL1TY ADDRESS <br /> L CODE # of TANKS <br /> 1 STATE ZIP at SITE <br /> T CITY <br /> Y APPLICANT CONTACT NAME <br /> AAPPLICANT/BILLING NAME <br /> P <br /> P � APPLICANT PHONE # WITH-AREA CODE <br /> L <br /> I MAILING ADDRESS <br /> CTYPE of APPLICATION <br /> A STATE ZIP CODE <br /> CLOSURE, INSTALLATION, etc, <br /> N CITY <br /> T <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> A <br /> C 1 1991) = $140.00 $ <br /> T ANNUAL FACILITY FEE (Prior t4 January , <br /> I 1, 1991) <br /> V tier to January 1,1991) ;170/TANK (after January <br /> E TANK FEE = $50.00/TANK (p 1996 <br /> F # Ta+�FE -- <br /> A <br /> 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 � <br /> A (multiply # by fee for <br /> C each year applicabte) section 25287 <br /> I 5 ears) See California HSS Code, <br /> L STATE SURCHARGE - $56.0 each TANK (Due every y 1991 through 1996 <br /> 1x $56.00 1986 through 1990 <br /> $ <br /> T # Tanks <br /> Y (enter amount and year) <br /> TANK ID <br /> PER CLOSURE (Removal or Authorized CLosure-in-PLace) x $159.00 $ <br /> C inimum per TANK) # TANK($) <br /> L CLOSURE FEE _ $53.00 per hour (3 hours m <br /> 0 <br /> S rmit, for review $ inspections TANK I.D. #{s) <br /> U TEMPORARY CLOSURE (A one-time Pe # TANK($) x $150.00 $ <br /> R $150,00 each TANK <br /> E TEMPORARY CLOSURE FEE <br /> P PLAN CHECK (Instatt• Ptan Review & Construction InspectiorTs) TANK I.R. #{sl <br /> per Facitity) ; 5424.00 minimus <br /> N P N CHECK FEE - $53. 0 per hour (8 h rs mini" p <br /> TANK I.D. #(s) <br /> R REPAIR <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /> Aa $159.00) S <br /> I r facility <br /> PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimnrm per <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION _ <br /> l <br /> S FEE _ $53.OG/hr FE. _ $ 53.00fhr <br /> C FEE = s53.00/hr TOTAL DUE s { <br /> ONLY .......... <br /> CE USE ................... ,<- . .�« <br /> OF�I <br /> ^� <br /> m >•�a� � •,.... x> �`"At•1Ctlkl'f Rt'�T1 I Cnc�K �1CASn e <br /> a `7 S x ✓! <br /> ]w.M A�]I f.�:tt�'Kaca 'Y.�: Y:-..�,:-',r.�' �)n.✓..~nv. <br />