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• SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> CatSIVL�) e C' <br /> I FACILITY ADORESS SITE PHONEao with AREA CODE <br /> L - — <br /> I <br /> T CITY STATE ZIPCOD # of TANKS_ - <br /> Y C�� C i8 at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P ''o el S <br /> P <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> A 030 <br /> 3 �. <br /> N CITY STATE Z LCOE TYPE of APPLICATION <br /> T <br /> S� "�"()•yt� d Z)-5 CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1 1989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> V <br /> loo roo �u> aa� azo $ S-60 <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) SI70/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) 150 115o1300130o 300 tb%) I I S <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks X 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 3 /-309 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TAN I.D. #(s) <br /> L <br /> L CLOSURE FEE - E53.DO per hour (3 hours minimum per TANK) # T NK(s) X $159.00 S <br /> 0f-ac- <br /> s <br /> U TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.D. <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) _ X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & 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 S <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = 5159.00) E <br /> N CONSULTATIONS _ UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> ......_...._........................................................... .................._......._.........................................................................................................._........................................... <br /> "S m:a ..".9.Y' SY>V�'i 'xw.<.::?>..fmtm•{S&T>` r`>Y0`.Y+<�y vFf YT OR <br /> ;�jE `p° ° �°0l0't ;t'Ai °LOC`=C 'v"U"1ST' C-O.)E AIOUil RCGb' <br /> ................ ..... m. 2-... ..5..............................: .: ...................,..... ...... s <br /> cu 21 n17 199V 17t7A/9n1 f `� Paan. 11 <br />