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F; _w <br /> A, <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION i <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAME <br /> A <br /> C SITE PHONE # with AREA CODE <br /> L FACILITY- ADDRESS <br /> 04E S�L -C � -4(0(.O <br /> I STATE ZIP CODE #atofITENKS , <br /> Y CITY �T / �KTC7� JZi�� <br /> A APPLICANT/BILLING NAME AP ICANT CONTACT NAME <br /> r-A G-oOct--%C_ . <br /> L APPLICANT PHONE # WIT" AREA CODE <br /> I MAILING ADDRESS <br /> C l.p � t- "'IL�IPAGa GV1-�L. i ��Fj^'�{lA�" i917 <br /> A STATE ZIP CODE TYPE of APPLICATION Gl Ga°JL�Rte% <br /> N CITY � q,, �q CLOSURE, INSTALLATION, etc.t�l'STi�&- Tl®� <br /> t -^�.t' <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> C <br /> PANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 $ <br /> IV <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) 517D/TANK (after January 1, 1991) <br /> iF 0 Tanks = 1986 1987 1988 1989 1990 ` 1991 1992 1993 1994 1995 1446 <br /> A (multiply # by fee for $ <br /> C each year applicable) <br /> fSection 25287 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California N & S Code, <br /> I 1991 through 1996 <br /> T # Tanks x $56.010. 1986 through 1990 <br /> Y (enter amount and year) $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) # TANK(s)� X $159.00 Lp1P <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/Inspections)J�A NK I.D. #(s) <br /> R TANK(s) X $150.00 = $ <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK <br /> P PLAN CHECK (Install. Ptan Review & Construction Inspections) TANK B.D. #(s) <br /> L <br /> A = $424.00 minimum <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) <br /> 775 <br /> R REPAIR FEE (workplan review & construction inspections) ±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 = $159.00) $ <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility <br /> M TRANSFER FFE < _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $53.00/hr $ <br /> S = $53.00/hr $ <br /> C CONSULTATION FEE _ $53.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE $ t <br /> OFFICE USE ONLY ...................... <br /> ................................................................................. ...................................................................................................................... <br /> ilei...aawas»aoHwuiem►»soee»m►»e►»ooas»►»maa»am»ew+»»xawe»azazoo»�oas»eoos»oa»moa»o►»a»aos»aaxaawaoan»aaamw»oaa»oo»aoawaas»aaxaw►»oa7a» »n �oeaa»as»ema►»u»o�sew+»aa»r»► <br /> g <br /> a $ <br /> » ............................. e <br /> om ON go <br /> saas:::s:wwo»ms»a»s»os aaoos ws»mu»»os»,®,e000a»»»ewawa ooaee•mmsfeoeoa»oe:eaamo�»o»m»aow»os»aa>»a»eaA�,u,aaeoe-»oo»o► kW <br /> mo am xx <br /> ).fCq; RTA%l 1�%f� W""xXX"# Stlb�AMY6 f SRffi .fit p % <br /> - R=nw 11 <br />