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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET 2 <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A �V <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> I. <br /> I CITY STATE ZIP CODE # of TANKS <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH•AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = Z 1986 1987 1988. 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) /t�'�' 7�<' �c�' !vc f c�G rfp SH <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks 4,'�x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> HZ_ jl Z__ $ �Z <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.Q. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = S <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 = $150.00 each TANK # TANK(s) X $150.00 = $ <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facility) - $424.00 minimum S <br /> R REPAIR TANK P.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 = $53.00/hr FEE = $53.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE ff $ <br /> OFFICE USE ONLY (0--(— 1.—,641. YX?l Y <br /> ............................. <br /> Mme.. WWOV ieM)000001000 HOWO`00«500Di�os ltlP>%' 'bitr l.K<e.dd«^FkP Yd6/fi Y W S?Yd{CS A4 { h 4Y tr'. k� V dMd?vG :dOCR9 NAp)OOP{OJ000 YAPf00oee%0010000Y 1e9«i0�e�b]004Maeea lda«�ma0> <br /> P '' a " 013 £ a.13`IST CO3E"Y "AAiOUNT'RC`J6 °C}fECK /CAS}H::"s}2GVIJ BY Te?%WNE '�WAY"#"'�'� »� <br /> $ <br /> a...................... ........................ <br /> ..................,..... ................... ,................................. .............................. ............................................sc <br /> aan.leeoleuue«leea xeee«loosleamseas meaxeaa�»ea:coao>7roexaoo xosroueo rw wn x!.xo-:oeo-:cecse r,:ro-:cu x+.a we{ao x✓.: ,� ^r:t�x.wa>xas+n meoxw xcaoe!eeaxnsasxw woe:eew.e Ana Dell, as xuem xea xwoazaraa+:oxes»ee»at <br /> l=MAP"aeAf1> 114% AI� fG�13'�fi7AJYY Yr1LNr;'AlY:S'3uYa:S..H::?•,,i�i:L::�:,+{x.:x?�i,�.`t;RtS:'?`:.^`v'•: '.::` ... .d:.'c:::"`L'^::;':.w"'�SY,.•ll�kS:.»Ji:tSY�+��FAbY sDY4R14b *W M"fm�1�Ai^Sw M MW M <br />