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0 a <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A Cone _S <br /> C SITE PHONE 9 with AREA CODE <br /> LFACILITY ADDRESS <br /> I <br /> T CITY /J�, STATE ZIP rCODE X of TANKS <br /> '/ /YU _ 05 at SITE <br /> Y 'GKL J <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P mac, l See <br /> L APPLICANT PHONE # WITH-AREA CODE <br /> I MAILING ADDRESS ^ <br /> C 6. 5� rte+'-- <br /> A STATE ZIP CODE TYPE of APPLICATION / <br /> TCITY �-� C.//' /' CLOSURE, INSTALLATION, eta / <br /> (a TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5700.00 i0o `/lo $A OO <br /> I f <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 799 ) <br /> F # Tanks ��. 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (ailt ear # by fee for `v G I �D $ <br /> 'T 70 <br /> C each year appti cabl e) J rJl 1 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 1991 through 1996 <br /> T # Tanks I x $56.00 1986 through 1990 <br /> Y (enter anaunt and year) J �r 5 5(y <br /> MCLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> CL 53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X 5159.000 <br /> S <br /> U E (A one-time permit, for review & inspections TANK I.D. #(s) <br /> R TANK(s) X $150.00E E FEE = $150.00 each TANK <br /> P PLAN CHECK (Install. Plan 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) = 5424.00 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 = 5 <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = 853.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS _ UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE S 1)G <br /> OFFICE.USE ONLY <br /> ........................................... <br /> .:.................:..:::: :ie>:...,:.1r:::e:��;:i.:;:::z:::::.::<:::y:?:>i'»:::n::X::;,:> <br /> . ,:beee <br /> s>sxm sws»mrweevm sem meww zxee wo.aaee„m M,n "". Y Y `Y 1:J• I y..�H 7 L <br /> »81Y`S IE�PS` iOYCvO1H6 ' OC•CO E" bl ST'"CCOE" i11d0UNT RC')IS CHECK #/CASd 2m BY 'IIYe <br /> a a <br /> s g <br /> 5...................... ........................ ........................ ......... .......... ...................•i%:'titi vi::ei%n:::im��: iii Y%iea:e<w4ex!6xve� ..• e.newesw:.eee zesrmemm.w eesmmmmmem=m <br /> wem,eerxeaeemeaexaeaweaoeeeee wza• :me mao:rs:vw sesa:me:crm.,.-.n:• <br /> �. RM RWBl lY6 q�t»AS%A%9#1 1�i9A%Y�#»LY#>)yf�YSD.Y�Y':f59.Y".:L#:wYi#.'X%Sfi;:,:'RcY.'.^:^:.Je•.:..�::i:`.:�i:�Y'::iii:`S:)GiiA:.:..YYAY�J�`u".Y;a59:pY�Y3L4��%t�YY# #m4�9AYY�Y�i <br />