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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 J 9 <br /> C L <br /> I FACILITY ADORE S SITE Ph6rE # with AREA CODE <br /> 3 209- s <br /> t CITY S TE ZIP CODE # of TANKS <br /> t 95206 at SItE J DOU <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME7/ <br /> P A !I p &V <br /> P ` <br /> L <br /> 1 MAILING ADDRESS APPLICANT PIONE # WITH AREA CODE <br /> C 1 7 IC <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> I L O0D CLOSURE, INSTALLATION, etc. C.0 0Sim E <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> I ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> I 5 <br /> V <br /> E TANK FEE $50.00/TANK (prior to January 1,1991) 5170/YANK (after January 1, 1991) <br /> F 0 Tanks 1986 1981 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (mut tiply # by fee for <br /> C each year applicable) $ <br /> 1 <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 /> T (enter amint and year) <br /> 5 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) # TANK(s)�_ K 5159.00 = C�' G U <br /> O <br /> 5 <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE = 5150.00 each TANK # TANK(s) K $150.00 = E <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 minimum per Facility) = 5424.00 minimum E <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 minimm/TANK) # TANK(s) K $159.00 = E <br /> A <br /> I <br /> R PIPING REPAIR FEE = 553.00 per hour (3 hour mini mm per facility = $159.00) E <br /> M TRANSFER FEE = 520.00 UUNAUTHORIZED RELEASE EVALUATION = 553.00/hr E <br /> 1 <br /> SF I <br /> C CONSULTATION FEE = $53.00/hr SAMPLING INSPECTION FEE = S53.00/hr 5 <br /> TOTAL DUE is/ (J(S <br /> OFFICE USE ONLY <br /> _ ...................... ................:................... _ ............ _ _ __ ___ <br /> S 00 S �. <br /> ...«.....»,».»...,.......»...»»......».»,.:»«....»».a»»»»»..»»..»»».»».»»i:wi:�i».. ::»:»a: <br /> .,ms»ttaxss=m aaa+mr.,rzm«mnszarma�arsaaswsaxxwFrxus,nzoaxcosasmnxvrmo�snr,x.xw.asms�aemx:mix.■maAyr■.�...r.w.rrrF.arw,..rsxe.... <br /> EN 23 032 (REV 4/8/911 It Pace 11 <br />