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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE L10RKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A �1 <br /> G 04a14V D P7 O <br /> 1 FACILITY ADDRESS <br /> T Kh SITE PHONE # with AREA CODE <br /> L os"� / c <br /> T CITY p/,/" STATE ZIP CODE # of TANKS <br /> Y S �x/� �� at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L S o <br /> L <br /> 1 MAILI G ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> DG <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T m tri,}' b - r CLOSURE, INSTALLATION, etc. <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 1 1990 1 1991 1992 1993 1994 1995 1996 <br /> T <br /> I <br /> V 'DL $ db <br /> E TANK FEE _ $50.00 each TANK <br /> F # Tanks x $50.00 1986 1987 1988 1989 1 1990 1 1991 1992 1993 1994 1995 1996 <br /> A (multiply by fee for <br /> C each year applicable) jd^" f <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 8 SAFETY CODE, Sec 25287 for applicability) <br /> I <br /> T # Tanks x $56.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> C <br /> L CLOSURE FEE _ $90.00 each TANK # Tanks x (90.00 E <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $80.00 each TANK # Tanks x $90.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) E <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each SUBMISSION/RESUBMISSION # Tanks x $110.00 S <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimus one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 530.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $ 50 CIO <br /> OFFICE USE ONLY <br /> rsir ze»:ie:iiiw»ii�ewei dee r:xe»:ioo:ww(:ie'eo iee»iieeixe:er:ieei sew:ioo:»oui»oi iaia'o>xro z»zsezee zwoi......•_..........iees zs zwro zu wsei ........................riwia7i zem:...rw:......:»ze::»... <br /> l � <br /> :..�b7.�. <br /> ....�^±.�.�SY ..L.....,a�� _3_�.J.... f.......�d........:.. l._b_`......._ ...... •. •••••••••• .••••••••••••••.....•..•..� <br /> x».me.Ae0 i1»»e.. ••• A».«e.ue..ue.x».:..»Ae..» <br /> iPY AM 0p9{fIN AIM fMe1AM1%ap ilNll MY%olxtAtlf MAW W: MMAMW tW AXYY1q BfeWW4Y WNRY6 MMiNK a'80 MY ALYM Ik%%A #AiAMfNnAWDI/Wi1WYtmLileM M0.iPW RtY RW AM xnV'15AY Yn <br /> FH 23 032 (REV 61901 it `� pose 11 <br />