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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> r' <br /> A 5yw k_ V' P sib CM <br /> c <br /> [ FACILITY ADDRESS / SITE PHONE # with AREA CODE <br /> L 533 4/NOM51ree - o?: <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y C'4 at SITE <br /> A APPLICANT/BILLING NAME - APPLICANT CONTACT NAME <br /> P s-{zric-FoN ./wetro Tt»u�,f. %� <br /> P V <br /> EIIAIYLIIG ADDRESS f S L/nblSctAPPLICANT PHONE # WITH AREA CODE <br /> ___ 2 3 -// 7 <br /> STATE ZIP CCOE Tor C',!f �! CLOSURE, N�1-STALL_AT I�� etc. <br /> TOTAL <br /> A <br /> C 1986 1987 7gHEE <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks nt '61986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 J� <br /> A (multiply # by fee for �O <br /> C each year applicable) - <br /> t p Q S IO:T Oma` <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T7# Tank� 6 x S56.00 1986 through 7990 1991 through 1996 <br /> Yamount and year) <br /> 33b"a $ boa <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) ZTANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X $159.00 = $ <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 = $ <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 853.00 per hour (8 hours minimumper Facility) = S424.00 mini mm $ <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 minimm/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = 853.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> " JSBcrtls J 3 z3 5 <br /> EN 23 032 (REV 1/10/91) ft }/8/j� Pace 11 <br />