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CUIN COUNTYPUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK P - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A <br /> 015141 <br /> C r6-6 <br /> I <br /> L FACILITY ADORES$ SITE PHONE 0 with AREA CODE <br /> t <br /> 7 CITY <br /> STATE ZIP CODE # of TANKS <br /> Y at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A -71 �' U.�4 aiC S'p5' ' 4 i' $ ELF <br /> T CITY STATE] ZIP CODE TYPE of APPLICATION nl�w <br /> :.L/4it3 7 !it/�/� g ,�.- y CLOSURE, INSTALLATION, atc. MOO <br /> Pr <br /> TOTAL <br /> 1986 1987 1 1984 1490' <br /> I ANNUAL FACILITY FEE (Prior to January 1, 1941) _ $100.00 <br /> V <br /> S <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1941) <br /> F 0 Tanks = 1986 1987 1488F!n <br /> 1441 1992 1 1 1995 1096- <br /> C <br /> (multiply IE'6v fee for <br /> Ieach year appllicabl�) 5 <br /> I <br /> STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California N & S Code, Section 25287 <br /> T 9 Tanks x 556.00 1986 through 1990 1991 through 19% <br /> Y (enter t and year) <br /> f <br /> C <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. #(s) <br /> 0 CLOSURE FEE _ $53.00 per hour (3 hours mini per TANK) # TANK(s) X $159.00 = f <br /> S <br /> R TEMPORARY CLOSURE (A one-time permit, for review/inspections) T I.D. #(s) <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK # TANK(a) X $150.00 = $ <br /> P PLAN CHECK (install. Pian Review & Construction Inspections) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hoar (8 hours minimum per Facility) = S424.00 minimum $ <br /> EREPAIR FEE (workplan review & construction Inspections) T I.D. #(s) <br /> A TANK REPAIR FEE _ $53.00 per hoer (3 hours minimum/TANK) # TANK(s) <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hoar minimum per facility = $154.00) S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $53.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S53.00/hr J.SAMPLING INSPECTION FEE = $53.00/hr S <br /> TOTAL DUE S <br /> OFFICE <br /> E L CUAIF RECEIVED8 <br /> 8 <br /> EH 23 032 (REV 4/8/91) ft <br /> YAMENT <br /> RECEIVED <br /> SAN jOAQUIN COUNTY <br /> PUBLIC HEALTH SE't%':�::ES <br /> ENVIRONMENTAL HEALTH <br /> 9 <br />