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• SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> NA � <br /> SITE NAME FACILITY CONTACT NAME <br /> ADDRESS p // SITE PHONE it AREA AREA CODE <br /> a STATE ZIP CODE # of TANKS <br /> 4 ���n at SITE <br /> T/BILLING NAMEAPPLICANT CONTACT NAME <br /> DDRESSAPPLICANT PHONE # WITH AREA CODE <br /> STATE ZIP CODE TYPE of APPLICATION <br /> T <br /> CLOSURE, INSTALLATION, etc. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> C 1986 1987 1 1988 1 1989 1990 1991 1992 1993 1994 1995 1996 <br /> T <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F # Tanks x $50.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply ## by fee for <br /> each year applicable) 69 <br /> yU �j 0 �U 5D $ 2 V <br /> S <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 8 SAFETY CODE, Sec 25287 for applicability) <br /> 1 <br /> T # Tanks_ x $56.00 1�16T987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> Y (enter amount and year) <br /> $ S6 gob <br /> C <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) <br /> L CLOSURE FEE _ $90.00 each TANK # Tanks x $90.00 $ —I <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (Only alLowed one time for up to two years) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $80.00 each TANK # Tanks x $80.00 $ <br /> P PLAN CHECK (Installation only) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) $ <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each SUBMISSION/RESUBMISSION # Tanks x $110.00 $ <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 1 <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr g <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> ...................................... ........................... ........:............ <br /> zao wee»�000zeemwoxeex0000xeei�oo�ee.ee,000x»»zooxwoow.woexeoeowozoezaeioz'aiiooa'eez'ooie'eee:xoozeez000>z»ioiz>iieeiow'aizao z'a000z'eez'oo iom'eozoixm'e>z'ao isiaezi6n'eozvoex'eoz8miiooaww»ii......ezoozoexe000zar we> <br /> ........ ............................ <br /> 4 o & �f <br /> rNfaff w <br /> S <br /> xN%m%UN%N Y(O.e xw%.W. O»»w.yo Rf»malas WNa Lyz"weazooie'ueie��j�,yp'�"�p"y'"�"'i igefiW �14MT9.W7�DAW 1nro0X»]b�>f(Nf�itt�vi%W W%SO Wq lNfp xio WTva'l�by f WWA <br /> fwYA3R5�'1 �A'PS8%RifAW1.451.0:Y93Wifd"ASSB�Aa'%�%XANTfA�%AV.'&l0 AQW3.0'A'.N3�Yf.43Y �N�`Y. WfAYAA➢YAM'9�. 9�'�13f94Y901.4Yf�`f.�'�N%�A'Yb.'A�1.0�Y.�'f��q'QW9M. � <br /> FH 23 032 (REV 6/90) ft Paae 11 <br />