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SAN JOAOUIN COUNTY PUBLIC NEALTM SERVICIW� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT. NAME <br /> P <br /> 1 !AILING ADCRJiSS APPLICANT PHONE # WITH AREA CCCE �� <br /> A orf Z/- _. 6� g/b dyo Ll <br /> N CITY $TATE 2tP LDOE TYPE of APPLICATION <br /> T CLOSURE, ;kSTALLATION, etc. <br /> TOTAL <br /> A – <br /> C 1986 199/~ 1988 1989 1440 <br /> T ANNUAL FACILITY FEE (Prior to Jenuary 1, 1991) • $100.00/YR. <br /> 1 S <br /> E TANK FEE S50.W/TANK (prior to January 1.,1991) T S170/TANK (after January 1, 1991) <br /> F 9 tanks �,)( � (-]O 19% 1987 1988 1989 1990 ?997 19+72 1993 t99L 7495 194b <br /> A each <br /> Lipa, # D fee tar � , <br /> C each year opp4lcebl e) <br /> L STATE SURCHARGE c $56.00 each TANK (Cue every 5 years) See Ws 4ornle H & S Ccde, Section 25287 <br /> II ...... —. _ .�..�. <br /> I Al7T*,ks-- a nd yea 1986 through 1990 1997 through 199Y enlout and year) .-- <br /> S <br /> PERMANENT CLOSURE (R�- Yet 9r A�thorixeE Closure-in-Place) _ 1 SANK I.O.per TANK) 0 TANK(9)__4#(a) _ <br /> C ./ <br /> L CLOSURE FEE • S53.CO per hour (3 hours minimus _ X $159.00 • '` ,Od <br /> p ...._.__._ _.�._. ._._..._..^�M.._.�. <br /> S <br /> U TEMPORARY CLOSURE (A ore-tire permit, for review/inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • $150.00 each TANK a TANK(S) X $150.00 S <br /> P PLAN CHECK (Instett. Pian Review S Construction Inspections) `Y, I.D. #(s),y_ <br /> L ......_... <br /> A <br /> N PLAN CHECK FEE - $53,00 per hour (8 hours mini.Tum per Fac'tity) - $424.00 minimm - $ <br /> —_ —mss_—=—.�.�..._�:.��.8�... _..,. --'—•• __ <br /> R REPAIR FEE (workplan review & construction inspaciipna) ?ANK I.D. #(s) ` <br /> P TANK REPAIR FEE • $53.00 per !your (3 hours mini,,"VTANK) s TANK(s) X $159.00 f <br /> A <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hajr niri. t per facility = S159.00) S <br /> M CONSULTATIONS UNAUTHORIZED PE EASE EVA: y,. ;H. SAMR� 9� SPE, I v <br /> I <br /> S _.�. <br /> G I FEE _ $53.00/hr fEE = S53 r"01hr FEE = f 53.00/hr <br /> TOTAL DUE S ADD <br /> OFFICE USE ONLY <br /> a:wr'r':».v+:.n.n. ...•.rrwu vna�raz vwu+....y �..::i:.n..r. ww»,.rww»» nrwr,rn ewv.a-...n,.wiahrow.-+vifwe4w ww' m++wn•An M./db"qm•• ... w� <br /> rrAn*rrnMfA•et+u Baa xwrsw.awr..,yor ewYX�.Nl1•x�sY..a�fxY:X#i(wi!e.:NMukrFwwe.•rx.rr+.ner..a.ese�Mwr(x+aeazacvramw wwrrei•w.wwwiewselmw as.:�t <br /> EN 23 032 (REV 1.:0/91) it =ao• 11 <br />