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" r <br /> ` SSAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ' <br /> F FACILITY SITE NAME / FACILITY CONTACT NAME 14 A gl)rvc 1_1 <br /> C <br /> L f <br /> FACILITY ADDRESS C�t1 Tuz At?. SITE PHONE # with AREA CODE <br /> 35i�t 5 T <br /> I <br /> Y CITY r vZ STATE ZIP CODE a of TANKS <br /> v�.. at SITE • <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> PE � � <br /> L / <br /> GMAILING ADDRESS APPLICANT PHONE # UiTff AREA CODE <br /> A �l( <br /> N CITY ��E ZIP CODE TY f APPLlCAiIOH <br /> fi LOSU INSTALLATION, etc. <br /> TOTAL <br /> I <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100,00 <br /> 1 166_ /Do— I Dv-" 5 I DLA <br /> V <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year apptfcable) �`J (jQ 13bo 300 � �? <br /> 1 <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 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) Ise 6 OF <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK 1.0. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)�_ X 5159.00 = S �7 7 <br /> 0 1 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK # TANK(s) X $150.00 $ <br /> P PLAN CHECK (Install. Pian 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 S <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 = S <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 /> S <br /> C FEE = S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE <br /> z^/'o° ,,1 J�1 �o <br /> OFFICE USE ONLY '� J� °� IISf�'�' Si fe ��✓ Co3 <br /> .......................................... ........... .,.' ,......................�.....,.............. <br /> M»wMx.o.`yr rew�we�xe.a�»N 1•M MMMIMF xWv]6M Xtx�:ii cG/A'x<s 9cb4:a Y?rulr aa Cvws.u. aA a•,;n .0}++. i.>::iS:t:!<a:J t^ aronM x<o.. <br /> .� .. ., {Y+ <br /> AW dD"'� <br /> %'TEVI?Ir XTOTW" ° ceC coli r`isT C'CtJE A110�11if'Rcvli` HEt'l� /caSH cw BY" t r `E�'°" `Ii `r''P`` " <br /> iNlsw waw•�aw••wwfM»S!M]W i,MM�N yMB�I� a»i:oa•tOatJ%:�:Y,l+fWP OCO t4Y4 iM MK:p XOY x<".MK9 ?'ice K{.YM:(+,P•w•.Y:S4:C-a:at<�:{si%KOt�:vM IM0e1nXM XM MMMi•MiW4MY aw�sM YN�!]MIIM II.K www» <br /> sW%W aw AW sm A*AM xx AM A==xM 9fx,Ygs:YlY MAfiCS:{2"..�:5`' i > -k:R�:Y;'.'!:�7:.:Y'."r`.Y is*A;:t f: fi=m mom"Ma RbX"WAWXW*XAWADNi0WAW <br /> cu 71 n47 tury 19/2Ann1 ft Paan 11 <br />