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*100r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F F CILj TY SITE NAME H I %`�J ^ FACILITYADSILITY CONTACT NAME <br /> C (�1U� ,//W- IJ <br /> I FACILITY DRESS TE PHONE # u' h AREA CODE <br /> , 11 a0 — <br /> T CITY STATE ZIP CODE Arof TANKS <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P S ?�';c '-e Caoq��a i'-9io5 <br /> I MAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> C Cao9 sa4' - 968 <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> t /Oo 1100 POO 0700 POO $ (ADD' <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1 1990 1 1991 1 1992 1993 1994 1995 1 1996 Q <br /> A (multiply # by fee for _ <br /> C each year applicable) 15 /$O 3W— 300 rj,A0 <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> 1 <br /> T # Tanks _ x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount aril year) f ry <br /> 5 <br /> 33 L- <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 u= $ 7 7 <br /> :P: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 5150.00 = $ <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 $ <br /> R REPAIR =TANK #(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 /> 1 <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimun per facility = $159.00) $ <br /> M CONSULTATIONS _ UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE _ $53.00/hr FEE = 553.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> ��.��. �.���.a«::»za'e:wlex'�sx�exwk:c:>z+:�.a'a'eixewesiw!.r�roC............................................ ..... .....__ ______..........___ .... <br /> yv ^as a.a n..;•x>•:m+e:.xs�x:s-.`�:i°;'.y.�:'�'•c"rws'i�^n...•s.. �css ias .. ... �. ems <br /> s '�P c 0�0 �'°iY "�OC"'LO�E�E �ISY CIAE AMOUNT R[VD tHEC�C �(1A5�1 C4 Bl� '�i '�L�PGEa"° ' R�I� »s <br /> ._.................... ........................ ........................ <br /> _......,. ..., ... .. _.. ........... <br /> mm- <br /> ru 21 nSl ron, 1J11410n\ $1 o,.... „ <br />