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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDEFRaMp STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY STT NAME FACILITY CONTAC <br /> /flea! /,-,r/G <br /> 1 FACILITY ADDRESS SITE P WRE 0 with AREA CODE 2 <br /> 1 <br /> T CITY /� STATE ZIP CGDE of of TANKS <br /> T <br /> GfN G'4 �5�) ( at SITE <br /> A APPLICANT/BILLING NAME <br /> APPLICANT CONTACT NAME <br /> P <br /> P <br /> L APPLICANT PHONE 0 WITH AREA CODE <br /> I MAILING ADDRESS <br /> ST TE ZIP CODE TYPE al' APPLICATION <br /> T CITY �/JDD�S�o 953 CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1 1987 1 14881989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) + $100.DO ; <br /> 1 <br /> V <br /> E TANK FEE S50.00/TANK (prior to Jaratery 1,1991) 3170/TANK (after January 1, 1991) <br /> F 0 Tanks 1986 1987 1988 11989 1990 1991 1992 1993 1991 { 1995 1 1996 <br /> A (reuttipty s by few for _ <br /> C each year applicable) <br /> L STATE SURCHARGE + S56.00 each TANK (Due every 5 years) Sea CaLiforrnis H L S Code, Section 25287 <br /> I - <br /> T e Tanke - R 356.00 1966 through 1990 1991 through 19% <br /> Y (enter wouit " year) 5 <br /> PERMANENT CLOSURE (Remove L or Authorized Closure-in-Ptom) TANK I.D. R(s) <br /> C <br /> L CLOSURE FEE + 153.00 per hour (3 hours minimum per TANK) i TANK(a) � X $159.00 ; ( g, cp <br /> 0 <br /> S <br /> U TEXPORART CLOSURE (A one-time permit, for review/impaction) TANK I.D. ka) <br /> R - <br /> E TEMPORART CLOSURE FEE • $150.00 each TANK / TANK(:) X (150.00 <br /> P PLAN CHECK (I mall. PLsn Review L Construction Inapaetions) TANG I.O. #(a) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) minims: : <br /> R REPAIR FEE (woriq:Aan review L construction Impectlons) TAXX I.D. 0(s) <br /> E <br /> P TANK REPAIR FEE ■ $53.00 per her (3 hours minimaNTANK) 0 TANK(:) X $159.00 * S <br /> A <br /> 1 <br /> R PIPING REPAIR FEE ■ $53.00 per hour (3 hour minimum per faclLity ■ $159.00) 5 <br /> M TRANSFER FEE ■ S20.00 lliiALITMORIZED RELEASE IVALUATION ■ 153.00/hr 5 <br /> I <br /> S <br /> C CONSULTATION FEE ■ S53.00/hr SAMPLING INSPECTION FEE ■ i53.00/hr 5 <br /> TOTAL DIX <br /> fns..�ias---•---._..-....T.........._....__._._�._. <br /> OFFICE USE ONLY —�......_._.,.�-- <br /> _ _ _ ___ <br /> ver SI..>•.AA 1wF IM..A IMA Mui..wR l.w I....A I.w Mw..MM MVI..Y..ttRII>A/ww I....A NIR■.MA MR 9MM.MR M..MMAA MM Iw.R MM AAM.M.1 I.M..M MR SIR IMA MAA..IM!MM..IMA IIIAMMA.cls I..IR 1151.I.lIM iA>Awlr Mw MM I.MR s s <br /> M ■ <br /> a <br /> Ave IwwAMM,I.R.IM.,M.�I.I.MI....R�I.RI.M..■.II�>_>_I�IIIA IIIA MR MR iM//A NIR 1MrA>�»>�>_�►■R M.IA ave ,I..■MR■R I�IMMlIIR MARA ..R III.■M..IR.»R■.IR I...>, <br /> macaw MK MwAMw■MFMMw/avemaMOW sM*MM MwMxMwsxMseissewwMONO <br /> ■eIMwwMwMMrrMerawMww/M11M1is/awwaveMw,Mw�revsave1MNIea1f�eMsslMiaveasw <br /> EH 23 032 (REY 1,181911 ft Pew 11 <br />