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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 /> �QAAOWid ( IlfS l C° � <br /> I FACILITY AD,v.DRESS SITE PHONE # with AREA CODE <br /> a� <br /> T CITY e7� STATE ZIP CODE I # of TANKS <br /> Y S ISG /� at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I NAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE 2IP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C Fzyi; <br /> 1987 1988 19891990T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00I /pD /DU /pp /pp S ;-bo <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = �� 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) jOD I /DO /DO /DO /DO S SOO <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 # Tanks2_ x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> E Z <br /> Ow <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) L <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X $159.00 = S <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 = 5150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours mini mm per Facility) = $424.00 mini mm S <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK [.D. #(s) <br /> E <br /> P TANK REPAIR FEE = 553.00 per hour (3 hours minimum/TANK) # TANK(s) _ X $159.00 = E <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = 5159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = E 53.00/hr <br /> TOTAL DUE E <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> C ?"v `z <br /> ■ Ss <br /> »e.»z»zs»oeee»»»s»»»z»zzer»wz.oes»»ze »e.»eee.ze. »w..zesze..z»»ee»ee <br /> »na�sraroxxaaaomfasxoxxreuaxawesauauwxexw`_� � � �xramr �wn:arxanxesraw`�� �aaxr� as �wi�xwmwxms <br /> EH 23 032 (REV 1/10/91) it Pace 11 <br />