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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES \� � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITTY,/SITE <br /> ��NAME FACILITY CONTACT NAME <br /> F C t/t, ,/ <br /> A <br /> C <br /> 1 FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 1 S DD �- <br /> T C[TY �` STATE ZIP CODE # of TANKS <br /> Y at SITE <br /> A APPLICANT/BILLING 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 TYP APPLICATION <br /> N CITY OSURE <br /> T INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1 Q� <br /> I 1106- 106- f <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> c each year appticabte) <br /> l <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> 1 <br /> T # Tanks_ X 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and Year) $ <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 5159.00 = f <br /> 0 <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 = E <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> H PIAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 minis E <br /> 'R REPAIR =TANK #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimus/TANK) # TANK(s) _ X <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimus per facility = 5159.00) f <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> l <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE S <br /> ,.,,..OFFICE USE ONLY (YWu'�F'JQ��� .... .............. <br /> �S" s' O d '='COCY[OI) '� IST CCOE ,1•Ibl11�T RCVO'- CnE C.0 .l/O.ISH� CIX "�i�`i RMITE'S"'I R f l 's <br /> yj�y�alMMtliM/Ii�Ya MiAglt�9.ika W.Y�V�➢.5� '.�^.Y�t:R39�""..'Y'..�,Y:Y.:RN:2�`A'�w:':+R.:::�,:,„rw�r::5 Y3:K��:'�”`s.....YaYNIDIY.RI'eY,%iira>ltassYa�r aata4ltf tliiM <br /> cw 21 n47 (DLV 17/7A/9M ft P.10e 11 �� <br />