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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION, <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET ` J <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> I STATE ZIP CODE # of TANKS <br /> T CITY <br /> Y 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) 8170/TANK (after January 1, 1991) <br /> F # Tanks = = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) F;'v 3z:*� z ""0 14(0 $ f L v <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 61> q �.C. <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X 5159.00 = S <br /> 0 x <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 (InstalC. Plan Review 8 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 $ <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 & 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 FEF = S53.00/hr FEE _ $53.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE S i' 7 <br /> OFFICE USE ONLY �1G' 79 7. <br /> .......................................................... <br /> 10060600}0100P 100P%0006f00650000P:pO b6Y i000ro%oa iO4.pdJ00D%<AY]006.Wei:P:«0:*.�iC•1{iJ.Yh\iti4:R`:£:£k:{>~v�'•}::?•il'::�: 43 . :0 \+ L<i?+Li6..MM4 X9G}ft2iA Jb061000:90ECO Ytls bO�blcOs 'imP%Oki6 <br /> » , Ec`PS 4's " O1 ii aC` OI} >" U:IST CO[SE':Y`:• 'AMOUNT RC'JO CI ECK <br /> g $ <br /> s <br /> S » <br /> �..................... ........................ ...... ................... <br /> 1p068006)0060611190 W000610001000M 1P06IOOF]40006%6P%Vi00PX60%09061tOP:Ot[S'•?Y.96 Yh6 X^%4'96}Y8'M'S'+•Y�W4 Wh'OU fMt'h £"A C'Y Yr 4•'A. fFtf•4L4:K0%IiM:KO WN 000096iK6i00016em6%Wi00MYMM2Mm6fp66160M►XN%Y]06ee6%061006 <br /> 1b�{At617�i17e1F 9h1�9�Yil�4DY1�JiR�lifCdFa`9.l>SGS'iaw'�ksrY'i..''i2....?:.. '#.S'S.`.:..•.3 }.].....L.: .....{x.. .i...v. .. :^.%fii}Y..`Yit%Y9?^,iiC�.,"Y" rYtdA0Y 9�0Y 1'%S1LLbyY A0Y1Wd A'4L11F150Y fd9tRR7F1� <br /> "M inn% s. <br />