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0 • <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <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 1 1988 1 1989 1 1990 1 1991 1992 1993 1 1994 1 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 />I <br />T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br />Y (enter amount and year) <br />$ <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />F <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s)_f '?,"'J X $159.00 <br />L <br />0 <br />C <br />I <br />I <br />FACILITY ADDRESS � <br />29a5 GU CST IJ CN�I�rnl� o,_ <br />SITE HONE wi h AREA CODE V Cw'�g. <br />C2 479 ' 9 -" SSPAiMGIV <br />T <br />Y <br />C <br />TUGiC �c�.�i <br />STATE <br />�A <br />ZIP CODE <br />9s ��'7 <br /># of TANKS RECEIVED <br />at SITE P <br />MAY 7 <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME SAN JOAQUIN COUNTY <br />P <br />� <br />n <br />`',UE VROZ E6 y � /j `1 <br />PUBLIC HEALTH SERVICE <br />/ /4 LEW /ad ENVIRONMENTAL HEA 1"H DMS <br />I <br />MA//I11LING ADDRESS APPLICANT PHONE # WITH -AREA CODE <br />�`S r <br />AV <br />4 <br />5OD <br />N <br />CITY (� S//TATE Z1P CODE TYPE of A��TIDN <br />0'n. C ��- 91VS8S. Q SU '_ `I MTAL�LAT1oN; etc. Or j�l }�/ �1 �� <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 1 1988 1 1989 1 1990 1 1991 1992 1993 1 1994 1 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 />I <br />T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br />Y (enter amount and year) <br />$ <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)_f '?,"'J X $159.00 <br />L <br />0 <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br /># TANK(s) X $150.00 = <br />$ <br />P <br />PLAN CHECK (Install. Plan Review & Construction Inspections) <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 />L <br />A <br />A <br />PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) <br />$ <br />NJ <br />PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum <br />$ <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 $159.00 = <br />$ <br />A <br />I00 <br />R <br />PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) <br />$ <br />M <br />CONSULTATIONS <br />UNAUTHORIZED RELEASE EVALUATION <br />SAMPLING INSPECTION <br />I <br />S <br />C <br />FEE = $53.00/hr <br />FEE = $53.00/hr <br />FEE = S 53.00/hr <br />TOTAL DUE <br />$—c' <br />! <br />OFFICE USE ONLY <br />JN! <br />