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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FAC TY SITE NAME FACILITY CONTACT NAME <br /> •F <br /> Af <br /> FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> T CITYSTATE ZIP CODE # of TANKS I <br /> Y7p�� '-i at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I $ <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) 5 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY 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 $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.R. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum $ <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE _ $53.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE S CJ e1 <br /> OFFICE USE ONLY 5> 1� aaa. <br /> f004 f0a.411W.V6Ipy YJ00P69006]0006P:004%04 A0406%Otr Y0.04]OC6%hL'4:tDO.vwWR C{4^..U�:tS:0:9:i{�iO:Cs4 kU .};.k.;.:n.;..:.;.,.:i vr:V:.w�?tih+i:tits%J.tih `K :MCi4X+66'Xt(44)OOD 9000`eae04 OPi%0P06%NX900i X000%OOOP BOO)J06%OOOP 1006XM <br /> » '$ Pa ' l t ' ' { "COI7c"•a T3:ISI 'CO[7E`� AAtOUNf RCW" <br /> s g <br /> Z3 - ! <br /> �� <br /> Is l5 vU R L-1 ftp <br /> M04l00.310a.004 1004 i000 xroM M(01004000004)004'100004 b04 XYAD'904:OOCf410 '0{90`4^093'04.40.N!-Y9+v 3M Ott N C' C \{+v-,2??}:!M}:M?C'9.00Ox:g04a-OP^004%000450041004 fOseOs%0F%Olp>%44%OOB>)AM%00W%MJOM 7oPO0R Mtl0A04 <br /> 1Y91 RYYAAdb1l5L0%StMA%SYdG>lt�>3�1>�137A3A'lskY}Yt7r"i rhY6 iYi�3L'}H,9y,d'F.'}RS.'�.Y...:3Y rh .....v s.w r. ...:..,.. ." ..'F.','.�?,�`!.'.^-.?:t.v>`�.":15Y:Sib^^"'.SD�Ai.X3 Y7CS.Y9U 11Ld1s 8Y6 fol0bt�%91 ^�Y>� iADY i70� f�L74'� <br />