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�f `P� itS� rz zr�sT /4 RUSy Ve. 1-) A24Sv16cv,, 9'-/&I_?/ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OIVISIOA � <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILEa <br /> ME FACILITY CONTACT NAME <br />� F <br /> win <br /> I fAtflADDRESS SITE PHONE B with AREA CODE <br /> L ,N E . <br /> 1 <br /> Y CITY STATE Z� 3�� # o} TANKS <br /> Y CK at SITE o <br /> A APPLICANT/MILLING NAME APPLICANT CONTACT NAME <br /> rff v fuuzc-A� 1Q 6a1PP- Sr..b,�iJ <br /> I NAILING AODRES t / APPLICANT PHONE # WITH AREA CODE <br /> A //00 /U . j z ��&- 2`7 -7 7 <br /> N C—ITfY- T STATE ZIP CODE TYPE of APPLICATION �7- <br /> T CA e13-L75 CLOSURE, INSTALLATION, etc. /�,arj¢'L <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) • $100.00 <br /> I 2 <br /> V <br /> E TANK FEE • 550.00/TANK (prior to January 1,1991) $170/TANK (after January 11 1991) <br /> F 0 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply 0 by fee for <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE • <br /> I S56.00 each TANK (Due every 5 years) See California N S S Code, Section 25287 <br /> T # Tanks $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-In-Place) TANK I.O. #(s) <br /> C <br /> L CLOSURE FEE • $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X 2159.00 = 2 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/Inspections) TANK I.D. #(a) <br /> R <br /> E TEMPCRARY CLOSURE FEE = 2150.00 each TANK B TANK(s) X 5150.00 = f <br /> P PUN CHECK (Install. Plan Review d Construction Inspections) TANK I.D. #(a) <br /> L <br /> A <br /> N PUN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = S424.00 minimm <br /> R REPAIR FEE (workplan review L crostructim Inspections) TANK I.D. #(s) / <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours min)aum/TANK) # TANK(s) X $159.00 = $ <br /> A <br /> 1 <br /> R PIPING REPAIR FEE • $53.00 per hour (3 hour minimum per facility = S159.00) 2 <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C FEE 553.00/hr FEE = f53.00/hr FEE f 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE OMIT <br /> sCee7�5'T 7 Trarcnr'"HT3'Y cn x all94'Ti CTb""`T'EUI.'"dMA1I" =Q=Ww' <br /> • �L $ + <br /> :':r�•.iswiwiiairwww•www:ria`wir wewrawaianr•i�wwa+iriawiawr:rir;wawiaair`•��• _____ ____' <br /> WAIN "W-- <br /> EN 23 (132 (REV 1/10/911 ft Pace 11 <br /> r.r <br />