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J 9 _ <br /> 7 ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND NSTORAGENTANK H REALTH OGRAMIVISIFEENWORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> l � r <br /> A Sm✓ 1 C-S6 <br /> 1 FACILITY RES SITE PHONE ! with AREA CODE <br /> L C{ <br /> I <br /> T CITY ,,// � !!''�� !!-- STA ZIP CODE ! of TANKS <br /> Y S(� -C(— vim ^7,$— ` at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L — <br /> I MAILING ADDRESS APPLICANT PHONE ! WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODETYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • 5100.00 f <br /> V <br /> E TANK FEE • 550.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F 0 Tanks • 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply fee for <br /> C I <br /> each year applicable) S <br /> LSTATE SURCHARGE • $56.00 each TANK (Due every 5 years) Sea California H d S Code, Section 25287 <br /> T ! Tanks x $56.00 1986 through 19901991 through 1996 <br /> Y (enter Wi t and year) — <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Clocure•in-Plate) TANK I.D. !(a) <br /> C <br /> L CLOSURE FEE • 553.00 per hour (3 hours mint" per TANK) ! TANK(a)_ X 2159.00 • f <br /> 0 <br /> 5 <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inepaetioru) TAMK LD. !(s) <br /> E TEMPORARY CLOSURE FEE • $150.00 each TANK ! TANK($) _ X $150.00 • f <br /> P PLAN CHECK (Install. Plan Review L Construction Inapeoti ora) <br /> L <br /> Al PLAN CHECK FEE - $53.00 per hour (8 hours minirm per Facility) • $424.00 mintaun f <br /> R REPAIR FEE (workplan review $ construction Inspect toro) TAMK I.D. !(s) <br /> P TANK REPAIR FEE • $53.00 per hour (3 hours minim WTANK) ! TANK(a) _ X $159.00 • f / <br /> A — <br /> I $ <br /> R PIPING REPAIR FEE • 253.00 per hour CS hour minima per facility • !159.00) <br /> MI TRANSFER FEE %20.00 UNAUTHORIZED RELEASE EVALUATION 253.00/hr 6 <br /> i <br /> [ CONSULTATION FEE 553.00/hr SAMPLING INSPECTION FEE • 153.00/hr = <br /> F�, F lI c� TOTAL DUE fl <br /> Q�1C-E..-U s aaaasami <br /> y 4 ,r ray <br /> [lC Cerm E <br /> EH 23 032 (Revised 4/8/91) Page 11 <br />