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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> rACILITY SITE NAME <br /> FACILITY CONTACT NAME <br /> A l D <br /> I <br /> FACILITY ADDRESS <br /> L L{ ITE PHONE # with AREA CODE <br /> IT CITYZIP CCOE # of TANKS <br /> Y '✓"' <br /> C4. L at SITE <br /> A APPLICANT/MILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> I I <br /> 1 MAILING ADDRESS <br /> C �] APPLICANT PHONE # WITH AREA CODE <br /> A f� 20f <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, etc. <br /> A <br /> e iauL <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) - ;100,04 1984 1987 1988 1989 1940 <br /> V f <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 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) <br /> I i <br /> 1 STATE SURCHARGE ■ $56,00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T # Tanks x $56,00 1986 through 19% 1991 through 1996 <br /> Y (enter amount and year) <br /> s <br /> C PERMANENT CLOSURE (Removal or Authorized C(osure-in-Place) TANK I.D. #(s) <br /> L CLOSURE FEE $53.00 per hour (3 hours minimum per TANK) # TANK(&) X fT59.00 ; fp ,r pct <br /> 0 �G <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 = <br /> s <br /> ENPtAN <br /> CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> CHOCK fed • 01].00 per hour (8 hours minimum per Facility) = $424.00 minimum f <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE ■ $53.00 per hour (3 hours minimum/TANK) # TANK(s) <br /> A X #159.00 <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = $159.00) <br /> S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C FEE 553.00/hr FEE $53.00/hr FEE _ ; 53.00/hr <br /> / ` $ <br /> OFFICE USE ONLY Ll.� 1L TOTAL DUE <br /> H.»"...?.+.Sxy...... ?rAIMw.Y4,Ar.M.�.M.Y�AHAMnMY�AM.wYM`moAMo.tP�AMW AreM..YwgfA�*7uW'7 AwM�IwIMr A.IMrwM rMesY�.g..lAMY iMYAf AMY .srsesscrA'rIKsr:Me+eMw'Yp`iAMr AMM.YriA�N AwM.Y aA�M.M.�Y�Aw�.rA.MwMw A.1 <br /> KriAiMwII.I nAIeM.s.A»..M..I..I:.M..•.Aw.MiY As.IwM..Ar'w.M.i.I..M:..A>s.Y..s�..a.w._...•..•.r....w.•f.•.A•..�M...A..M...Aie.Mq.M...Aus..Ie.M.s...Aa•wM•.+M.wM An�" �" Ar.,.M�.w.Y.. <br /> .......,. iAf1YN <br /> EH .�i <br /> sa[ <br /> 23 [132 (REV 1/10/91) ft Paae 11 <br />