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+� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY SITE NAME FACILITY CONTACT NAME <br /> u5CmAje- Jim Baif /0' <br /> `Sgti SFA C'Lcj/.��J <br /> FACILITY A3 ESS i Icor SITE PHONwith REA, paFN gPUNC ,` <br /> IW F <br /> YCITY STATE ZIP CODE 11gS�OS atSITE <br /> S{�c k bN C F <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L s Cfz1fJ &f [T" <br /> I MAILING ADDRESS APPLICANT PHONE # WI H AREA CODE <br /> C <br /> 23173 SCA, 1Q00a4 D - 6 -763 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION so,(SMn�)�n^'af <br /> T OC CLOSURE, INSTALLATION, etc. ..11 <br /> A TOTAL <br /> C 1989 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 7986 7987 1988 <br /> 1 $ <br /> V 7990 <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 1 1993 1994 1995 1996 <br /> A (multiply #by fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> 1 <br /> T # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> T (enter anoint and year) <br /> E <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) # TANK(s) ;L X 5159.00 <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 = E <br /> P PLAN CHECK (Install. 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 E <br /> R REPAIR FEE (Workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minima/TANK) # TANK(s) X $159.00 = f <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility $159.00) S <br /> M TRANSFER IEE = $20.00 UNAUTHOR I2ED RELEASE EVALUATION = $53.00/hr E <br /> I <br /> S <br /> C I CONSULTATION FEE _ $53.00/hr I SAMPLING INSPECTION FEE _ $53.00/hr E <br /> TOTAL DUE E D t'o <br /> OFFICE USE ONLY <br /> g .h7 ...... ... ...u y 3 ..........V......... ......... . ... ..... ::........ .. .. . . ... ... .. ..R.!w................... .....9..�h. i ..................s <br /> �7 �� _XMYO,laVi�AarAOe ,.,.... ........#x <br /> EN 23 032 (REV 4/8/97) it 07 ae 11 <br />