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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 0 <br /> 1 �! <br /> F tt�� �� JbA 14 Oatal go LL , <br /> �7 O v ( 0 <br /> IL6A349-534 . <br /> I FACILITY ADDRF�S SIT PHON with AREA CODE <br /> L q3n lG �oZ <br /> I <br /> Y 39 <br /> CITY STATE ZIP CODE # of TANKS <br /> aO at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P ,, <br /> P 5 L C 0,6spf <br /> 1 (LING ADDRESS APPLICANT PHONE # WITH AREA C E <br /> A o�6 a1-1&5 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION to <br /> T I � 3� OSU , INSTALLATION, etc. <br /> ANNUAL FACILITY FEE (prior to January 1, 1991) = S100.00 TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T <br /> I S <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) 8170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply —A—.-fee fee for <br /> C each year applicable) $ pn <br /> I170 <br /> L STATE SURCHARGE = $56.00 each YANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks= x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount end year) <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) J] <br /> C (� <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = S tJ <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 = $ <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 mini mna S <br /> REPAIR TANK I.D. #(s) <br /> R TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = $ <br /> E <br /> P <br /> • A PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility) = S159.00 $ <br /> I <br /> R MISCELLANEOUS EVALUATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> (when applicable) (when applicable) <br /> FEE = S53.00/hr FEE = $53.00/hr FEE = $53.00/hr S <br /> TOTAL DUE S <br /> OFFICE USE ONLY v� <br /> .ww»I........��...... <br /> a TER Tiff w" wdAyr <br /> a <br /> ■= /06''- CHAF7 / 3Ls $ /Si''� a `L ............. .. f�........ ....�/�/? ............ . s <br /> ...................... ............... ...... ........................ ........................ ............. ............ <br /> EH 73 032 (REV 12/26/901 it Pace 11 <br />