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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> U'WERGROUNO STORAGE TANK PROGRAM - FEE WORKSHEET"'' <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> C <br /> IFACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 71 <br /> T CITY ST TE ZIP CODE_ # of TANKS <br /> Y S �C ,GFry" /� C�J �)i at SITE <br /> A APPLICANT/BILLING NAME (` C APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDR S APPLICANT PHONE # WITH AREA CCOE <br /> D <br /> A ,u ZLD S C �a <br /> N CITYST E ZIP E OSL,01 APPLICATION <br /> T _ OSU INSTALLATION, at <br /> TOTAL <br /> A <br /> C 1986 1987 1 1988 1989 1990 <br /> TANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I i� ooev ;ooA' 000' 5 SOo°o <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = �_ 1986 1987 1 1988 1989 1990 1 1991 1 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) c-O,noM �D� <br /> I <br /> L STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> 1 <br /> T # Tanks$ x $56.00 1 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) eyo[ <br /> —5,6 `rO s crn <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. CO— A//�– <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/in spec ti ors) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) 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 f <br /> R REPAIR FEE (workplan review 8 construction inspections) =TANK #(s) <br /> E <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours miniam/TANK) # TANK(s) _ X $159.00 = f <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = $159.00) f <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE _ $53.00/hr FEE _ $53.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY �c�N�` L� <br /> 517....... ..t[ !°.1.'.hl.. ......�l;;........ .1 ' ... ..00. OO .. . ._.?g.._ ..� .......... s' <br /> nc xs aw xa aow w uas xa>tx:axt aw xaa an zn.wr,.m r.r.ao Ms away xar>»r ar aw rr aw>�w:war>r�ami rr w,wa w ww wz aaw>aa xn awn r.,rw ars n...r.w a..r xiw w aw <br /> EN 23 032 (REV 1/10/911 it Pace 11 <br />