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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 /> A <br /> C <br /> IFACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> I <br /> T CITY - STATE ZIP CODE # of TANKS <br /> YLOA C 4 at SITE <br /> A APPLICANT/BILLING NAME f I APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, 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 / <br /> V <br /> E TANK FEE = 850.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1 1991 1 1992 1993 1 1994 1 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 1 $ <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = 853.00 per hour (3 hours minimum per TANK) # TANK(s)y3 _ X 8159.00 = $ <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) _ X 8150.00 = S <br /> PPLAN 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 minimum $ Z <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) _ X $159.00 = $ <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 /> I <br /> 5 <br /> C I FEE = 853.00/hr FEE _ $53.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE E 5 <br /> OFFICE USE ONLY <br /> •.....••.••••••••••••••...•..•.••••••••••.......•••••••••...••...•........."'..•'........':vriivaei«i.ws: raz%c"+inu .6w::o:ao>xo:«dixa'xiii6iinw rae:aeeaxeeeeowieie ieaa»wee»eexw»zos wm'eezroiwoee»oe x'eexa'ai ieeers <br /> zw xasewsw zewsxmxmwww»oe wx»xroxxwxroxsae xoe x«ae xw:on:m�n. <br /> gS16Tr ° O t C" ea• a•111XST'ICY]iSE'zre:r.:�T10UNT�RCG6:`m �•CFfE � /�A5Nx„`r L'�0 8�7"°"` i '� E "'�' iA°x°'� g <br /> g... ...blo..... kfky...... Q...:....... . $ 1. 1.°....... 2 �- ►.).-9 g <br /> ............. .. <br /> ............ <br /> xas zewx..»xswaeimus»nx»xw»zw».roezwxaw.aexwce.-.w.. ..uxaaxeroa mo:«uo:eee xa w<nx<axa�:oxo,;:aeeee.�rvn aw»».w�w rae xew:aro xww:roe xee zwwxwieeemxwxaeix»»asxwws»omswmxm <br /> x�0Df9.��^I�iAY�1R%A`��Yl.'�IRU.`Y�S 1UAY A:Y 9fSL.'sY:YH:f:>:J.KR.`Y�n:'k.Y:!A�f.`X w.y�Ss.:Srox'.T.'65::.w y'�?�#��'�'bS1Y RSY9S..`#aY.tl 1J�AY��Y9.04Y dBlA�IA%�9Y�l�JiAtl1�l�14Y�lAY <br /> t• 1 <br />