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" SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES 10 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSSEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A U _���5 <br /> W4+ 7 7,� <br /> C JactSITE PNON 0 with AREA CODS, <br /> 1 FACILITY ADDRES --�- V <br /> L <br /> �w.,_ ODE 5 of TANKS EXls In J <br /> T CITY <br /> °� at SITE <br /> Y �O c <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> POC rn a OA <br /> LAPPLICANTPH09 $ WITH AA COD <br /> ( MAILING ADORES <br /> C u ur <br /> A STATE ZIP CODE TYPE of APPLICATION ( <br /> N CITY CLOSCNtE, INSTALLATION, etc. n�� t4 10A <br /> T SN`u n1P <br /> TOFAL <br /> A 1986 1987 1988 1989 1944 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 $ <br /> I r <br /> V $170/TANK (after January 1, 1991) <br /> £ TANK FEE ■ S5O.00/TANK (prior to January 1,1991) <br /> F 0 Tanks = 1986 1487 1988 1989 1990 1491 1992 1993 1994 1995 1946 <br /> A (multiply N by fee for $ 1 0 <br /> C each year applicabte) I `✓ <br /> 1 <br /> L STATE CHARGE _ $56.00 each TANK (Due every 5 years) See CatMOMZMTiforM a N S S Code, Section 25287 <br /> I 1991 through 1996 <br /> T 0 Tarns x $56.00 1986 through 1990 <br /> Y (enter s wunt and year) $ <br /> CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. 0(s) <br /> RPERMANEXT <br /> CLOSURE FEE ; $53.00 per hour (3 hours minim per TANK) TANK(s)__-__� X 5159.00 = <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.O. 0(s) _ <br /> R N TANK(9) X $150.00 = $ <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK _ <br /> P PLAN CHECK (Instatt. Ptsn Review & Construction Inspections) TANK I.O. i1(s) <br /> L <br /> A S 2 �� <br /> N PLAN rMCK FEE - $53.00 per hour (8 hour$ minimum per Facitity) _ $424.00 minim <br /> R REPAIR FEE Cww kptan review & construction inspections) TANK 1.0. M(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 a $159.00) S <br /> R PIPING REPAIR FEE _ $55.00 per hour (3 hour minimum per facility <br /> N CONSULTATIONS t;NAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S FEE _ $ 53,00/hr <br /> C FEE = 553.�lhr FEE = $53.00/hr _ P1 <br /> TOTAL DUE <br /> OFFICE USE .;;;;;;;;;;�u;;:w;ii»;;N;iiaidt fei9dq»ia.»»+ee»:»+w <br /> .....esvAai.........0 vnie+iw ivop�o�iaoods%�odgpg eeevaiwf+ie»zse»»a��1 oe►eea'ial iiw www$iir»a««nmwe��iagris iaa7peiiiC <br /> °. ; . ruw.S..s»::m.as±wwwiwms»eeeieayw'� 1... <br /> fit.; <br /> ........... .... <br />