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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> I <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y 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) _ $100.00 <br /> I $ <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170/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) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK 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 - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum $ <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 $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE = $53.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> woo xz xmoe woo>oc000 woo w0000 woo woe 000coo w:oXwo»wvX<::o:!".o:c:".ws•>o:ub:4:•::4:b:o>:4:4;:4xv:;4;:;::•;; ;r.<c; : ::::<. 4:•:4:>:•;:b:!•>:<bz:e:4w:o>a�o sa�oXco woo woXb woo wcoro zoo>00000 woo wooco woo ooco xoao Xto:coo <br /> ;»x.>..•.:,,.c!.+:•Y:..;.;,..;.:..:..;.`•;:r.: e>;: e>;>;;:.v%^isi:;.::.;:.raHE*C•i;>s!.:;.;`AS'.v.,..;.:""...... v....:.• ,,,>� a :� x <br /> '"1)I'S7 CGOE ' Ah1CUNT RCVI) CfiECK "#/CASH"'"" RCVb <br /> » $ » <br /> g...................... ........................ ........................ ........................ .................................. .............................. .................... ...........................................................ss <br /> woo)0.OP%0000 woo%0000 woo%0000 w00 woo%0000 w00%V WO Xt0\aOF:iSO:K<4)v.:0:<!O:<n:!<.:..v,.i:v::!O;v!.:L:!!4:Ci}:!!^i:C!!�i:•i::O;:i•i:n :�i:!•:.}:.i�Y!4:!.ii:!•r:b:•X0:4:("4 if!KO.`000 wO0�i0%OO w00%0000 w00%0000 w00 J00000 w00 JOOOOO w00 w00%0000%OO w00 <br /> >D�ALo11bSOb6>ti6d�h�bY>Wd RL3bY A76>5519,'.Ob�1?h'l;bblh'S3X>aS.�o).Y:.:Y:::< i:`�:%:S::v":;•`:::ij::i'"`.L':��i ii::� �:J i'S�i S`::<:;i::ji:�i:�i:�:::::r:::`;�:� �:::::i i::2'::2�i::::Jl i.S..:.w::0f�'l%>D3l:LUi AD7'�'l�l Rt20ol%9f7�'l��l R3L'a'S:bYl Ofd <br /> EH 23 032 (REV 12/26/90) ft Paap 11 <br />