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SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> • UNDERGROUND STORAGE TANK PROGRAM - FEE 'WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A n1UNI FIEF QjkOL <br /> S c�oS��t (�, D'UARq, <br /> I FACILITY ADDR€€SS SITE PHONE # with AREA CODE <br /> L 30 rJo o- A A Aaoq - s99 - a 13l <br /> I <br /> T CITY __ 11 WATE P CODE # of TANKS <br /> T Q OV Vp� AP CODE <br /> 6 at SITE - Oq <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> eoe.) UN( FICO c�C1�oU � �STR�CT ��NH6ZpC, �}gY�,il7or� ��mW <br /> 1 MAILING ADORESs, APPLICANT PHONE # WITH-AR CODE <br /> A 3o1 �oRTH R ACOA �� 30 ( 1 - Say - 96 -5 <br /> N CITY:E <br /> /STATE ZIP CODE TYPE of APPLICATION PJ t4 <br /> T -6 O N `` 1 953 6 CLOSURE, INSTALLATION, etc, rn9 jDI FI ep�4 <br /> A TOTAL <br /> C 1986 1987 j 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I 5 <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) s <br /> 1 <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> 1 <br /> T # Tanks K $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK 1.0. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X $159.00 = s <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = 5 <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE 553.00 per hour (8 hours minimum per Facility) = $424.00 minimum S <br /> R REPAIR TANK 1.0. #(s) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) # TANK(s) ;;z X 5159.00 = S <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = S53.00 per hour (3 hour minimus per facility = 5159.00) S <br /> N CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE = S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE 53 , <br /> OFFICE USE ONLY <br /> (9TANCURT <br /> lC '�'�L�OC"C00t1 �•U •..'^,O tr':<sa:^. "ZC'vD"'� Cii"c�6.- /C�t5"ri`"" CGD'"ra" '�it' cELcfle0'�"�'�Eai' fT, exms <br /> . I I � <br /> saa=s:asysm�ansesxan�asrmrs..:s r•xzm.-.:-::xa,::ruc.:ctta:�:�r.:,::av;tt.:�.H..:r.;.�„M�ssx��:>i:'s^.: cx::,xan�:as,ixaas a'amnw�r mw ars aosau,oawaasrr <br />