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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE' <br />ENVIRONMENTAL HEALTH DIVISION <br />dDERGROUND STORAGE TANK PROGRAM - FEE WORKSHttT <br />F <br />A <br />C <br />FACILITY SITE NAME <br />h1 cona <br />k o <br />/%/o L) r/° CcCO <br />FACILITY CONTACT NAME <br />- <br />FACILITY ADDRESS <br />i' <br />a 11fI <br />SITE PHONE # with AREA CODE <br />I <br />L <br />I <br />T <br />Y <br />CITY <br />_ G� `)_ <br />STATE <br />ZIP CODE <br />' 7 <br /># of TANKS <br />at SITE •, <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />T <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />P <br />C <br />FEE = $53.00/hr <br />L <br />FEE = $53.00/hr <br />FEE = S 53.00/hr <br />E <br />I <br />C <br />MAILING ADDRESSn w `� <br />PA, rME <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />N <br />CITY E <br />TYPE of APPLICATION <br />T <br />A) <br />CLOSURE, INSTALLATION, etc. <br />P <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />PU66 HEAWIN COUNITY TOTAL <br />C <br />L <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X $159.00 <br />C <br />— <br />S <br />U <br />HEA1 TN <br />L 6i' s� <br />1987 <br />1988 <br />1989 <br />1990 <br />T <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />C <br />FEE = $53.00/hr <br />FEE = $53.00/hr <br />FEE = S 53.00/hr <br />E <br />[ <br />$ <br />V <br />E <br />TANK FEE _ $50.00/TANK <br />(prior to January 1,1991) <br />E170/TANK <br />(aftEr <br />January <br />1, 1991) <br />F <br />A <br /># Tanks �_ <br />(multiply # by fee for <br />1986 <br />1987 <br />1988 1989 <br />1990 1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />E <br />C <br />1 <br />each year applicable) <br />L <br />1 <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) <br />See California H 8 S Code, Section 25287 <br />T <br /># Tanks x $56.00 <br />1986 through 1990 <br />1991 through 1996 <br />Y <br />(enter amount and year) <br />E <br />P <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />C <br />L <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X $159.00 <br />E <br />0 <br />— <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review 8 inspections <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br /># TANK(s) X $150.00 <br />S <br />P <br />PLAN CHECK (Install. Plan Review d Construction Inspections) <br />TANK I.D. #(s) .3 <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X $159.00 = <br />L <br />A <br />— <br />A <br />N <br />PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = E424.00 minimum <br />,r Cj <br />E `–} <br />R <br />REPAIR <br />TANK I.D. #(s) <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X $159.00 = <br />E <br />A <br />— <br />I <br />R <br />PIPING REPAIR REVIEW B CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) <br />E <br />M <br />CONSULTATIONS <br />UNAUTHORIZED RELEASE EVALUATION <br />SAMPLING INSPECTION <br />I <br />S <br />C <br />FEE = $53.00/hr <br />FEE = $53.00/hr <br />FEE = S 53.00/hr <br />TOTAL DUE <br />$ <br />OFFICE USE ONLY rpl0"" f v <br />.................................................................. <br />w�we ww www Mw wM wwM wM a" 0114 A MWXer <br />AXr AW Alai Air AaM Allr AY�Yr Ali Aa{ %Abi Rar Alxr SO.r>�L`lr }lYi'.C. <br />cu 7t n" rory 17/7//0(11 ft <br />.............................................................................................................. <br />x<e zao:ucae:e:> x«u:ew:ucce;x»:x<re!r..+:<>:<o x•:n :�x<v :c.a r:<.v:;:e,:aa:aw xc�:✓w.> xw xn <br />Y. <br />x!e:✓.e :HSt0:99J xp.N :'!Cf :C:>CO:+.00 xP4 x!f\\•:<iM:(>p:> w.; ,v,�C n;NC •:.•••> ix>:ae %ace :Ke Mww ane ww <br />r4:s n>r;:,r a;.�.rx zr: s., Y ^.�s,;,,z;::, ^a.:: s:�.^.:s rz?::� �;: ^; �Y i':Y i;:5;..17Y:Gi�>�.•�"•Y:/YYw": <br />Pnoa 11 <br />I_Z3 <br />]Mwe M wMe IMS iM.N 1�� t�M /w wM www W� W <br />Rear Arr Aaw All{ AaM AIM Aaw Air aar xaa.r mer xst <br />