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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F - /i <br /> i <br /> / L L <br /> 1 FACILITY ADDRESS SITE PHONE # wi" AREA CODE <br /> I <br /> y CITY STATE ZIP CODE atof TANKS <br /> Ci <br /> A APPLICANT/BILL! G NAME APPLICANT CONTACT NAME <br /> P C _ <br /> L <br /> I MAILING ADDRESS _ APPLICANT PHONE # WITH AREA CODE <br /> N CITY ST ATE ZIP CODE TYPE of APPLICATION <br /> T 77'7 —I G:<c (�• �' z j`; CLOSURE, INSTALLATION, etc. <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 1988 1989 1990 1991 1 1992 1993 1994 1995 1996 <br /> A (multiplyy�i 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 /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. $(s) <br /> C <br /> L CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = $ <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E ITEMPORARY CLOSURE FEE _ $150.00 each TANK # TANK(s) X $150.00 = $ <br /> P. PLAN CHECK (Install. Plen Re.._., u Ccnst rust,c„ Inspc,.,,ons) TANK I.D. :(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 minimum $ <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPA e h <br /> FEE _ $53.00 pour ( hou s minimum/TANK) # TANK(s) __j X $159.00 <br /> L_ L <br /> RI PIPING REPAIR FEE _ $53.00 pek hour (t hour minimum per facility = $159.00) $ <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $53.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $53.00/hr SAMPLING INSPECTION FEE _ $53.00/hr $ <br /> TOTAL DUE $ <br /> OFF[ US ON Y _. <br /> . .......... .........1................................ ............. . . .. ...............,...,............,..,.............,.............................,...,......,......................................................,....... <br /> ................................I-!...,,,.,,:. ,..,,,�,,..,..,,:.:..,.............,.:.r............................................................................................................................. <br /> .................................:f:f:..................:EiffEE::::ilii:iiif:i sEi::ifEE:fE:E::EfEfEEa.Effff.............E fffffffffffaffffEEEf;EEiififffHEft:FffffEEfffEff......fffffffffEf.fffffffffff:......fff:ff::fffffffffffifEffi fffEfifffffffffffiF iE..................fifffffi:iif:::ffiffc fifffEi <br /> E <br /> SUEEPS # COMPUTCR # LOC CODE DIST CbDI -AMOUN> KCVO CHOCK %CASH" - RECEIVED BY DATE-R�C'IVCD <br /> 1 C f f [..._...... <br /> ............. <br /> ................................................................................................................................................................................................................................... ::::::::::::::: :::::::::::::::::::::::::: ............................... ................ <br /> EH 23 032 (REV 4/8/91) ft Page 11 <br />