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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 <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> S 71. of 0,4O <br /> T CITY / �I STATE ZIP CODE # of TANKS / <br /> Y 4-0'0 at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L r a- <br /> I MAILING ADDRESSP APPLICANT PHONE # WITH AREA CODE <br /> C G e P'of'„'y r:�) <br /> A <br /> N CITY .. i1 �. STATE ZIP CODE TY APPLI <br /> T - �U�((��1�N(:(111N� CLOSUR STALLATI etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1 1988 1 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00/y1t. <br /> 1 E <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1 1988 1 1989 1990 1 1991 1 1992 1 1993 1 1994 1 1995 1 1996 <br /> A (multiply # by fee for <br /> C each year applicable) <br /> I <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 I x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 6(9 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) —>,D 7s —O <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) # TANK(s)_L 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 TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = E <br /> PPLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A I t+•k <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = 9424.00 mini mm E t�2Q.a0 <br /> R REPAIR FEE (workplan review 6 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minim RITANK) # TANK(s) x $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour mini" per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> C I FEE = $53.00/hr FEE = 953.00/hr FEE = S 53.00/hr <br /> TOTAL DUE E o <br /> OFFICE USE ONLY. <br /> .............................................. ...« ............. e>e....' e.=,. _...�.» .................. ....................... <br /> ...................... <br /> Sao»aaaaxr.e,.w,,.=.e,eze.r=ew»e.se»e»iszeieizeszeeeiiiaeze:zee,�wie.=.w..=..eoxeox.oxe,ee»ee»oepe z.e =.e,o.,e=eeesue..Y:.:ee:ze:i::,ea»a..,xw=,ee.»w <br /> rarr <br /> a 7075 _S4WO 7/ 2/ F 32U ESSC'tr . C,p II1 '`+�' . �-%. I ISScl <br /> r <br /> MCMMI,ev,W a„MI„,f111,CMN=a=,a„IIM,i=Mr]YHa%al(wMl'N,ftt�)MC)1N,NAroaMM%NesMM Ws.WtY%M%WY=MMN,�MM M,iM f'W MM wwvfm lTete un KKiM znw wN,illi fi.1MY�111�1,1MN'IMf11if1i,Y I,Yifxr <br /> f W3NN faYlwaY MIiMIMtf W MV:NMEf WfIRSAM9MP.Y9.ffif.�'�'�'ppsY�9.0tlYM%9#RY%%MO�Y.i9D.tlttY%sA%WYI%k%JaS by Mi9.0%c 9�f R'��R'dTt 9.rof9M MRRAYIAMYt�1UiNafWMilMli}MfMaRA%Y�i <br /> EH 23 032 (REV 1/10/91) it Daae 11 <br />