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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SI E NAME ACILITY CONTACT NAME <br /> S ��1� ��S t� t QVTIov oI G �is x 1.it <br /> I FAIL( Y ADDRE SITE PHONE -)wit AREA CODE <br /> I <br /> T CITY �n^ ,tRA)E ZIP CODE ! of TANKS - <br /> T Val �.Jj at SITE VIJI= <br /> A APPLICANT/BILLING NAME ADPL CANT CONTACT NAME <br /> P <br /> P c Tra l�l y Yk L�CI� (� �1�C 1 i CLL ✓�1 v <br /> I MAIµ�yyC�y ADDRESS i A LICANT.�P"i�NE N WITH AREA CODE <br /> C J 1J� UftV tl1 �J ll\Jet 1f LAY' �7 -8\ 57 <br /> A )5Il TE 2I nn,, TTPE o} APPLICATION <br /> N CITY`t�,it� L-V3 C' °-SLS CLOSURE, INSTALLATION, etc. <br /> 1 ��JJ TOTAL <br /> A1986 1987 1988 1989 1990 <br /> C <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • !100.00 5 <br /> 1 <br /> v <br /> E TANK FEE _ 150.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F N Tanks = 1986 1987 1988 1989 1990 1991 19921993 1994 1995 1996 <br /> A (multioly fee for 5 <br /> C each year applicable) <br /> L STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H 5 5 Code, Section 25287 <br /> T ! Tanks x 156.00 1986 through 1990 1991 through 1996 <br /> Y (enter mnount end year) f <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. !(s) <br /> L CLOSURE FEE • $53.00 per hour (3 hours Mint" per TANK) ! TANK(s)�_ X (159.00 • f g'"�j" o`er <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TAMC LD. N(a) <br /> R <br /> E TEMPORARY CLOSURE FEE • $150.00 each TANK N TANK(s) __ X $150.00 • f <br /> P PLAN CHECK (Install. Plan Review 6 Construction Inspections) TANK I.D. N(a) <br /> Li <br /> A $ <br /> NJ PLAN CHECK FEE - $53.00 per hour (8 hour$ minimun per Facility) • $424.00 minimum <br /> R REPAIR FEE (workplan review $ Construction Inspections) TANK I.D. N($) <br /> P TANK REPAIR FEE • 553.00 per hour (3 hours minimum/TANK) <br /> nuN TANK(s) X 5159.00 f <br /> A <br /> R PIPING REPAIR FEE _ ;;;A <br /> $53.00 per hour (3 hour minin per facility $159.00) <br /> S <br /> M TRANSFER FEE $20.00 UNAUTHORIZED RELEASE EVALUATION a $53.00/hr $ <br /> S <br /> Cl CONSULTATION FEE _ $53.00/hr SAMPLING INSPECTION FEE • 153.00/hr 5 <br /> TOTAL DUE <br /> e <br /> LUL CCIDEi 9!ST Out <br /> s^ F-IFECE1Vfb <br /> aF e "'• •.� 'i:4 r'8➢11Si11Er' l^. iiia <br /> EN 23 032 (REV 4/8/91) it Page 11 <br />