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SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE 'WCRKSHEET <br /> FACILITY SITE NAME FACILITY CCNTACT NAME <br /> C <br /> I FACILITY ADDRESS ,� /l � `J SITE P'MCNE with AREA CODE <br /> L <br /> I <br /> T CITY STATE 2IP CCOE of TANKS <br /> Y S�G ff5z� C Cj�� ! at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE ( TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> I S <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) # TANK(s) X S159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 3 inspections TANK I.D. #(s) <br /> R <br /> TEMPORARY CLOSURE FEE = S150.00 each TANK I # TANK(s) X 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimum per facility) = $424.00 minimum S <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 3 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) $ 9 U� <br /> M CCNSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S ip <br /> OFFICE USE ONLY <br /> ...................................................... <br /> JON.000 b0000)O0O 60)00 bN JOOON 600 Joon b00o0 600'A01»b.V::<::0:<!O:L:UA\C)::N::!::J:>:0.:::v)'^:•)::•i::3:i'i i'l.O:^:•:�i i i::•:::•:•:i:r.;.:'r.>:!.;':i?:!!:•i}}n:.::.>:L'.�M�.CO:OJKO:+.JO�(CfWO oCO 6N.60'AO JOoO booty JOOO)COON i00s•JseeOO 600 bN)000».000 <br /> »vs S.t 7S COMP a GC CCbE' zaUIST CCDc ,Ir, U1CLNf"ZC'17 <br /> ChtCC­ CASH... �C �Y <br /> '� SH .sl ; s <br /> .D „ <br /> �. o 1...... ....................... ........................ ... 1................................ .. ........................................................... <br /> 6NION 600»6N).00000 JON MOON%N]000%000060060000600!(O60:tN:KK•>�, >:MO:t^:M}v0•K+w :Mi:^ ' :NA:!KN:KO: ••••••%MJ000600N 6N6W06N 1000N boo l00oN 600%00600006N 6N <br /> t�65i> JU1ti> JDbY ALY A75%�a+l?7%Jb�JI�.�)k7,:ir)f::.i.::::f:. .:5?,`S:):,,'Y:;Y::,...::7.'Y.,,..,..�.v.,......::>•F.,..,..,.v.,..,.,. r):5:..vAx:f'»... .J�:,:.�:d JYe�t smtaY xsf Jeta�f,tett Jtato�JtYi 3e�l2sl JutX%eD'ol JULi1 JJei <br /> CW 77 nz'� focv 17/?A/on) it Paoo 1.1 <br />