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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> +r.► ENVIRONMENTAL HEALTH DIVISICH <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WCRXSHEET <br /> FACILITY SITE NAME <br /> F FACILITY CONTACT NAME <br /> iJoy �1[(��3 f--)C(4 <br /> " CT 11 sJ �C <br /> I FACILI Y ADDRESS <br /> LSITE PHONE 0 with AREA CODE <br /> I EIA-EIA- ME— <br /> T <br /> V, f E - <br /> T CITY <br /> Y 12A _ STATE ZIP CCOE # of TANKS <br /> CA �5 3%G� at SITE <br /> A APPLICANT/BILLING NAME <br /> P <br /> APPLICANT CONTACT NAME <br /> 1{ : C- '�l�l -, Ij L L CDP{'- C} <br /> I MAILING ADDRES i / APPLICANT PHONE # WITH AREA COOE <br /> H CITY ���� TATE ZIP CCOE TYPE of APPLICATION � <br /> T TT <br /> rc� ,q e,13-7-7-5- CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) $100,00 1986 1987 ' 1988 1989 1990 <br /> 1 <br /> V S <br /> E TANK FEE = 550,00/TANK (prior to January 1,1991} $170/TANK (after January 1, 1991) <br /> F 0 Tanks = 1986 1987 1988 1984 1 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year appticable) � o $ Q V <br /> I 3 c <br /> L STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> I <br /> T it Tanks_&—X $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> d U S <br /> C <br /> PERMANENT CLOSURE (RemovaL or Authorized Ctosure-fn-Ptace) TANK I.D. #(s) <br /> L CLOSURE FEE - 153.00 per hour (3 hours minimus per TANK) # TANK(s) X $159.00 = s <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 1(r TANK(s) X $150.00 = 5 <br /> P=CHECK <br /> l. Plan Review b Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N53.00 per hour (8 hours minim_rs per Facility) = $424.00 mfnimus5 G/ <br /> T- <br /> R REPAIR FEE (workplan review L construction inspections) TANK I.D. #(s) / G� <br /> E <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minimus/TANK) # TANK(s) X $159.00 $ <br /> A <br /> I <br /> R PIPING REPAIR FEE $53.00 per hour 0 hour minimus per facility = S159.00) $ <br /> H CCNSULTATICNS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C FEE = $53.00/hr FEE = 153.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE $ ?J <br /> OFFICE USE ONLY <br /> ............... „........ .........._.......,............ <br /> r..rr.�....ry»�+w�pwt r,.t,.....»n.w,.»a..»w.�.u,..sp=...ta».rw�r..n;�:�.:.»»ru..ys..n......w.wr.�... w�:'i:»s.::».::s,i:::N.:::v::»...... w:�:,.�:isyi:�w,M�,ng. M..�.w.rrw.o...:S <br /> S -rS a'� C UTtr( A nC`0 `C !7P SI C �1 f riC1i.1 , p/7i�"w ' C 1Ytt} 'w�"r'wr ' l3'R1t K�l.t1vtU 'wmr <br /> s � C) <br /> g 7 <br /> ■.......................... .1.�.}. �1 ,. .................... ......... , .$ . (...L?..� `...... .cl.. . ........ .. J � —��- <br /> r <br /> rrrrrwwrwrsrrrrr*rrw rrwwr..r....raw.+....�.rwww.:ws..r.wr.rw...`n+..rww►»..a..rr.�»...�wr...w..r.+....•a.wiiw J� ...••.•,,••,••••••••.••IT•• •..•...........! <br /> Mw MMJ1MIw Mw MN*MMI MMM MY MM XWK MM MMIC MOM MMM fw MMM MMM MM MIME Mt MIM/MMI"MMMi MWM Mw OW MM MMW MW MMM Au AW AgIIM.-.. .TAM trot Mw Mt Mqt MMMpw Mi MMIM MM IMwM MIM Mr M Mit MM <br /> EN 23 032 (REV 1/10/913 ft Pace 11 <br />