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\e SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES r../ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F � / <br /> C <br /> 1 FACILITY ADORE S � SITE P E # with AREA CODE <br /> L <br /> 3 oy_ - s $ <br /> ( CITY j!!E ZIP CODE # of TANKS p <br /> Y U F•EC• at SITE I OOCI v <br /> A APPLICANT/BILLING NAME ENVIRONMENTAL HEALTH APPLICANT CONTACT NAME <br /> P PERMIT/S€RVICES ��s1�a;, � ,� p2 <br /> PL <br /> I MAILING ADDRESS APPLICANT P E # WITH AREA CODE <br /> C <br /> A 7 Z <br /> N <br /> CITY tttZ4P CODE TYPE of APPLICATION <br /> ( �OD < CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> I ANNUAL FACILITY FEE (Prior to January 1, 1991) _ =100.00 <br /> V f <br /> iE 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 1992 1993 1994 1995 1996 <br /> A (mil ti ply M by fee for <br /> ar app <br /> C each ye _ <br /> I <br /> L STATE SURCHARGE _ =56.00 each TANK (Due every 5 years) See California H 6 S Code, Section 25287 <br /> 1 <br /> T # Tanks A =56.00 1986 through 1990 1991 through 1996 <br /> Y (enter arrant and year) <br /> C <br /> i <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L CLOSURE FEE = 253.00 per hour (3 hours minimum per TANK) # TANK(s)�_ K =159.00 <br /> O = _/ co <br /> .(',rj <br /> 5 <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) K $150.00 = S <br /> FA CK (Install. Plan Review 6 Construction Inspections) TANK I.D. #(s) <br /> CK FEE - =53.00 per hour (8 hours minimum per Facility) = $424.00 minimum 5 <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = 5 <br /> A <br /> I <br /> R PIPING REPAIR FEE _ =53.00 per hour (3 hour minimum per facility = $159.00) 5 <br /> M TRANSFER FFE = $20.00 UNAUTHORIZED RELEASE EVALUATION - 553.00/hrIj <br /> 5 <br /> I <br /> S <br /> C I CONSULTATION FEE = S53.00/hr I SAMPLING INSPECTION FEE = 553.00/hr 5 <br /> TOTAL DUE 5 Q/_) <br /> OFFICE USE ONLY <br /> ......................................... ............................................... .:».....e......» <br /> waw..si...: ......wo. we. w..r.w..a. •• •••..•...•....._................•... <br /> sEa +r ° a (€ ° T° rs °° ) r <br /> ;' . .................1........................1........... .......1................. _� ..: ...... '1. <br /> .. .: ,»....»..._.»....... ......».. ._.....».: .». .. ..�»:(:,.:�:R�::: .:... . :» <br /> EH 23 032 (REV 4/8/91) it Li Paoe 11 � <br />