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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F C <br /> A <br /> C <br /> I FACILITY ADDRESS }-- SITE PHONE # with AREA CODE <br /> ':-: C <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y — - 1 at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I MAILING ADDRESS - APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY 0 C T 111990 STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> FACILITY FEE _ $100.00 each SIP' !(jY,EMQES TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> 1 <br /> I E <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F # Tanks x $50.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply ## by fee for <br /> C each year applicable) $ <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 8 SAFETY CODE, Sec 25287 for applicability) <br /> 1 <br /> T # Tanks x $56.00 1986 1 1987 1988 1989 1990 1991 1992 1993 1994 <br /> t 1995 1996 <br /> Y (enter ;mounand year) <br /> E <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> C <br /> L CLOSURE FEE _ $90.00 each TANK # Tanks x E90.00 E <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> R <br /> E TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks x $90.00 E <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) E <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each SUBMISSION/RESUBMISSION # Tanks x $110.00 f <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE _ $35.00/hr E <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> Mirzee wee wzwa»ewz»zeer zee zeezeeee we.xoevox.....ee.a..epee.a..e>we.ee.e.wase;.;.zm»e.oxa.xoeeo zee w�eocxa zeoee zoe.oeee..e we.eeeee.e.wwe..ee weee......ewe.se.zwa zoe ueae.x..eeee.»»...»w..a.we <br /> :.._ '.. $ ^C 1I Vi i.T....... ...I0.I:.�..L.: ...... <br /> Mw <br /> w»maW»IMM Mwe w.Mwe w»wN»wx wM rwwe Mvs ww »twewmeww waysw w.w wws Mwa»» ••••••••• <br /> Y(Ye weoMMawN MYSalav w' sMT<iwN%WotxawM lWNapM%HV.�.. ih INe MMw wMwN We[a a»w <br /> aew xxsvwaxMY9B1{MVXWMNAPxMANtANNW%f0.Y Wf MWWWfO%a'm#&a�x.OYLKOfMBSNW6x9lWYMii#f�� SAWRkiY NYYN KGHM 0.0'(d�M1O�� WYiA'!JIMXN <br /> FH 23 012 (REV 6/901 it Pnne 11 `� <br />