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0 <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> 1 FACILITY A16ESS SITE PHONE # with AREA CGDE <br /> I <br /> T CITY / �`� KST'ATE Z1 CODE # of TANKS <br /> Y .LrtC /f 1,rat SITE <br /> A APPLICANT/BILLING tNAME [ 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) = $ <br /> 1 .00 <br /> I $ <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1 0 1993 1492 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) ,1p��' Ia)y <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See Ca \fornia H & S Code, Section 25287 <br /> 9 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) j <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 8 inspections TANK T.D. #(s) <br /> R <br /> € rTEMPORARY CLOSURE FEE = $150.00 each TANK it TANK(s) X 150.00 = $ <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum S <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE = S53.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE 3 <br /> OFFICE USE ONLY <br /> %00%0)0000a)90>%OePa}OeP MOOaa ea06bM M0KPY9CP%OY+0 i0>4%0016:Si9 GYW1 R .FW!? ,.d J,.,3 h ti Y f§ .+HY`0a+000KYS<c0 boa]oOe WWYXdh leW.d Mea Ynoo0P J0ePJM000%OP]606100o0e:K4'M1`� <br /> g' Iii PPS coi '--ne;O g "G'I*57 CME" NT "CVIS Ch"E CX !'CASA �Vf7�YEiY dY `Iff.ffE " <br /> Lcs Q <br /> g.. , ��` .... ....................... . y <br /> %W M0006%06)0000a%Oa)QBe0a iP06)004100.%6YOOD SGie0a�M010e'N450e6 kK6a:S;8:P^AA WYS4 K6idM i24 tlt9*Yh i4 VY?C MYO YCS60:'X!^}%?M�A:{efC6:0{6 X3WM. MOD 1006)000eaY0e0 M000a%0a Me00a M00)a000a%0a f0a6 Mee06%00#0? <br /> .'7� k�35AGitll� �{ .' ,'Q�+�x.�il�ii�� �i$:1i4"�.ry/✓a'+i.�i)W'2+f.v:r:...v:.{]$'p. :..w Yrvv rvvY rv.:rv..ii�:w�r:;inn Y.'."e:wv'�}'ifi"}iw�A�iYY2+`:.2v 7M1b 1�AY Y�9190YR�.OADY.�J� �7� <br /> CSE 7t n37-forir 120AjQnl Fr <br />