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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 /�eAD r74 E / k/J D S?A>GE <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> I <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y A 9 -202 at SITE / <br /> S oc �e ✓ <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P A4 G �"aflei.vf-- <br /> I MAILING ADDRESS APPLIC NT PHONE # WITH AREA CODE <br /> D P.G /JoK .7 sz 209 /73v _ C P/ <br /> A STATE ZIP CODE TYPE of APPLICATION <br /> N CITY <br /> T CA 9yrGC CLOSURE, INSTALLATION, etc. c4ox4AE <br /> /�G FFSA�+7o-✓ <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> S <br /> I <br /> V <br /> E 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 (multiply # by fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> I <br /> T # Tanks z $56.00�F-:1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) l X 5159.00 = s I 5 f7z) <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 = 5150.00 each TANK # TANK(s) _ X $150.00 = $ <br /> P I 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 mini man per Facility) = $424.00 minimum $ <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) S <br /> M CONSULTATI OHS UNAUTHORIZED RELEASE EYALUATI ON SMIPLING INSPECTION <br /> I <br /> S <br /> C F"eE _ $53.00/hr fEE = 553.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE $ ` 5�' c D p <br /> OFFICE USE ONLY <br /> g <br /> $ r s�. z3 3"� 9 /........... <br /> EH 23 032 (REV 1/10/91) ft Pace 11 <br />