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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - FEE TAT LTH DIVISION — <br /> UNDERGROUND STORAGE TANK PROGRAM - AL <br /> FACILITY CONTACT NAME <br /> S FACILITYSITENAME —77 h L • V <br /> 1 <br /> T SITE PHONE if with AREA COD <br /> E FACILITY ADDRESS <br /> d / SJJ}TE Z rnnETANKS <br /> at SITE <br /> CITY <br /> A APPLI CANT CONTACT NAME /✓� efJ/�/�{S <br /> P <br /> P APPLICANTTIBILLING NAME / S <br /> � <br /> Or APPLICANT PHON/E�0 WITH AR A CODE <br /> C NAILING A DRES <br /> N / / /VQ U ATE ZIP CODE TYPE of APPL <br /> T CITT (Closure, tallati etc.) <br /> G TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 xxxx XXXX XXXX XXX% X%Xx S XXxxxxxxx%X%% <br /> A <br /> xxxx xxxx xxxx xxxx xxxx s xxxxxxxxxxx <br /> xx <br /> D <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) <br /> I5170/TANK (After January 1, 1991) <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E6 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 0 <br /> # Tanks = a 1982 L' 1� <br /> F (multiply # by fee for5 17 <br /> A each year applicable) XX%K %%Xx XXXX %XXX XXX% <br /> S <br /> C <br /> I TANK PENALTY FEES ASSESSED %XXX X%%X xxxx x%%% xxx <br /> L <br /> rs) See California H L 5 Code, Section 252 <br /> 87 <br /> I STATE SURCHARGE = 556.00 each TANK (Due every 5 yea <br /> T1988 through 1990 1991 through 1996 <br /> Y # Tanks_ X 556.00 l(O b� <br /> S / <br /> (Enter amount and year) <br /> 'fe'r <br /> TANK I.D. #(s) <br /> C PERMANENT CLOSURE (Removal or Authorized C(osure•in-inace) $ <br /> L # TANK(s)__ X $234.00 = <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> S TANK I.D. #(s) <br /> U TEMPORARY CLOSURE (Plan Review d Inspections) 5 <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br /> 11 <br /> 11 <br /> Pi INSTALLATION PLAN CHE11 CK11 (Pl11 an Rev11 iew 6 Construction Inspections) TANK I.D. #(s) 3(Z O <br /> L S <br /> A $624.00 minimum S� <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) <br /> R REPAIR FEE (Workplan Review d Construction Inspections) TANK I.D. #(a) $E X $234.00 = <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minima /TANK) # TANK(s) $ <br /> A = 5234.00 minimum <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) S <br /> R $234.00 minimum <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimunVFACILITY) <br /> M TRANSFER FEE = s20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br /> TS <br /> I ;;�] <br /> S = 578.00/hr <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE 5 <br /> FOR OFFICE USE ONLY <br /> , m , Ham 'Is <br /> um!m!lom;m!1. !e!mammr DATE RECEIVED <br /> 'Lmmi'ama:ImiWC�N,CO!4..143M1i!4'mm!m:0!mmm10iE6it, " :::C <br /> m SWEEPS # COMPUTER # LOC CODE DIST CODE AMWNT RECEIVED CHECK #/LASH RECEIVED <br /> m <br /> 5 ..,. .nmmm. m!nm m!mW!smn- . �. <br /> :.,........._-r±=_: !!!!::m_.v: �,r�_;_ ,r::m!n!rv!rv!!,e=i:w!m5mm:;^m .�sr�t. mm:w=Ly!malm!mlcrsmmemm:�ua!mawr <br /> milimlim!itla!!im!!iF:!_?!P!isiiu!!Ilia:_ till wilt: mT'W1214m1:mimTa..::' LIR:WWNI:i—JvJil Rd!!m!!41'FLI n:v4limlWmayiv+6o.— <br />