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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 CONT CT NAME <br /> Chevron 051,qN7; <br /> C <br /> 1 FACILITY ADDRESS SITE PHONE p w th AREA CODE <br /> 3 y S. El >7oraz& 5*fzf N A <br /> T CITY 1 STATE ZIP CL�,E�//�/ 9 of TANKS <br /> Y 71JY) f.,R .. -2b6 at SITE l remaminy, <br /> A APPLICANT/BILLING NAM APPLICANT CONTACT NAME .,7 <br /> Gv�rrdfn5�'v � mel oenfles <br /> L <br /> NAZI IADDRESS APP "ON E <br /> / D �c96ff � ��5' <br /> A <br /> (l7 <br /> N CITY / Q�J STAT ZIP <br /> �OD��y/ TYPE of APPLICATION <br /> T L (� 77..77 CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 19 1) = $100.00 <br /> I lDD $ /00 <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F C Tanks = 1986 1 1987 1 1988 1 1989 1 1990 1 1991 1 1992 1993 1 1994 1 1995 1 1996 <br /> A (multiply Y by fee for <br /> c each year applicable) 50 151D I O!c <br /> 5D 50 /�'O 5 y�Q <br /> 1 <br /> L STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California N S 5 Code, Section 25287 <br /> T 0 Tanks_unx $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amot and year) 5l0 1 —6-& <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Placa) TANK 1.0. 6(s) <br /> C <br /> L CLOSURE FEE - $53.00 per hour (3 hours mini" per TANK) 0 TANK(S)_ X $159.00 = f <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d inspections TANK I.D. P(a) <br /> R <br /> E TEMPORARY CLOSURE FEE - $150.00 each TANK 0 TANK(s) _ X $150.00 S <br /> P PLAN CHECK (Install. Plan Review i Construction Inspections) TANK I.O. #(a) rp-Asir!1Vq 01 fm or <br /> L <br /> A <br /> NPUN CHECK FEE . $53.00 per hour (8 hours mini" per Facility) - $424.00 minimm RECEIVED s <br /> R REPAIR TANK I.D. Y(s) V <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour 0 hours mirimm/TANK1 a TANK($) _ = 'F. F_S <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION a $53.00 per hour 0 hour minimus per facility = $159.00) s <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE = 553.00/hr FEE - $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE 5 <br /> OFFICE USE ONLY <br /> ........................_...................................................................................................................................................................................................................................... <br /> s alp'?r ' 4-4—MnjIffE? 'VrslT�ca aIOUII�'RvC�iD�. eCYf`�y�,l5H�M nn B'f�jwn"C�I�E <br /> :...................... ........................ ........................ ...... 5........_3.(x............ _9.. .......... . .... .. ...L!.-_�a. ..9./...............................: <br /> `w si wr as ar is rs lir eis siv a ags na mw'sx:c:�x".^s�iiti,.:s'zc�r��`—»�"xn x�::a:H:ax:>zc's ax'r::s;� �s aa;>sz sx::..s�,aa wr aew s mo m ws a it.:i is w:s a� <br /> cu n nal ,acv 170A/9n1 fr Pnee Al <br />