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%%. `We <br /> 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 /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L p(( <br /> 1 STATE ZIP CODE # of TANKS <br /> T CITY <br /> Y I at SITE <br /> A APPLICANTAILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A STATE ZIP CODE TYPE of APPLICATION <br /> N CITY CLOSURE, INSTALLATION, etc. <br /> T <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 /> I to D /00 /00 /vU /00 S SOO <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) 8170/TANK (after January 1, 1991) <br /> F # Tanks = 7= 3 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply by ee for / <br /> C each year applicable) ?NP NO ASO (5(1 10 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanksx $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter unt and year) <br /> 8v s ZSrD <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 <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) _ % $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 mm $ <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) _ % $159.00 = E <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE $ <br /> OFFICE USE ONLY ...... <br /> ._.......................................................................................................' i... <br /> ...............................NEC�C........ <br /> .......... <br /> u <br /> z.zwz.enrv.er.,...emxe..e.xem.»ee wwee.ee eoeesewwxew.rae=<exsae:ee:a«e:en::'arnrao>mmxnwww.r..i:«ew:c». <br /> N{:?t /ll(5H <br /> s I " <br /> •.............._.«_ ........................ .....�/............ ........................... ':,:,•,..ia.'r.?.bii;;iroi:heia':; . 1 . ... ..m::::>vewf:».w'»:»iwi»:»:»»»z»»�» <br /> xexemeraw:xa w:.v <br /> %AtW{M1iAi8'AXAIiAWYaHiA% RDYRWLY A%�AY SYi9P.NY -WL AT::sY.�,^�•:r;i�'q�,::::C.T):'h:kw.i:�"f.�"Y�SLYR9!>Y.xY�S Y�.'aYtl�li%�itlfRR%�Y#AYSMtWUY�lAY[9A�AA 8R <br />