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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A C -�z <br /> G <br /> 1 FACILITY A)DDRESS LL <br /> I �� SITE PHONE # with AREA CODE <br /> L CI L_ <br /> T CITY \ STATE 2IP CODE # of TANKS <br /> Y I„vl at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> 1 MAILING ADDRESSa 4=, APPLICANT PHONE # WITH AREA CODE <br /> C <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> I CGT 1 1 199 CLOSURE, INSTALLATION, etc. <br /> FACILITY FEE = $100.00 eaqVfi MW-1AW6AVh TOTAL <br /> A <br /> C '9 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> r <br /> 1 x <br /> V <br /> E TANK FEE = 150.00 each TANK <br /> F # Tanks x $50.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply# by fee for <br /> C each year applicable) x <br /> I <br /> Lff x56.00 each TANK (see CA HEALTH 8 SAFETY CODE, Sec 25287 for applicability) <br /> I <br /> T6.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> Y year) <br /> x <br /> PERMANENT CLOSURE (Removal or Ctosure-in-place) <br /> C <br /> L CLOSURE FEE = $90.00 each TANK # Tnnks z $90.00 x <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 x <br /> P PLAN CHECK (Instatlati on 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 E <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, mini num one hour to be paid on plan subnittat) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = E30.00/hr FEE = E35.00/hr FEE = x35.00/hr x <br /> TOTAL DUE x --- <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> "a...��L7Y......... ......'.TcJ.�.[..... ......C2...j.... :.: 4.. .......I s.... 1.J.�e........... ! .� .1....... � I UL. to..... ...i <br /> wx..�ee..enuxPGM MIW MN NM GIM�YM MMN�r x«rr . w....eee. .ee»uoe aaeee.».e..ii:iioee xewe w.Geewxs xawxmN zi::eee.i«i..eee.a.:eiiwSis>,a x..wrPzei.:eo:A'e::�:weee::ee e. <br /> wORMRNM MNIR0.M WYAtl A4G1Wf.MHfW.91Ad"10Y. MSG�MMP0.G.NaM.O%RSM RM RXV.OMMAMM9MDGkG RM A3AV N#YS3iiWP 0.l0 MNG AKRhY. W%kf%N.bAOailM W.M PM.HNl`R'N%N HH A+Y lw <br /> FH 23 032 (REV 6/90) It Paae 11 <br />