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SAN JOAQUIN COUNTY PUBLIC WEALTH SERVICES " <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A j� y / r� <br /> C 1 t /Cr r 6 1n 11 rJ'f{t <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L 2AJ 1 zo <br /> T CITY /y S 7E ZIP CODD�Ef # of TANKS <br /> Y ���c���� at SITE <br /> A APPLICANT/BILLIN <br /> NGG NAMES�j APPLICANT CONTACT NAME <br /> P1�[C.[/ _ �/L 7' <br /> L TF�in/ <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C �3/ tri. w47rc 104j Zay, Z 65 3 <br /> A <br /> N CITY /yJ ATI: I ZIP CODE TYPE of APPLICATION <br /> T /'��0 �j�� Qj CLOSURE, INSTALLATION, etc. C�l -L <br /> A TOTAL <br /> C 1986 1987 1 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> 1 � <br /> Y <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1940 1991 1992 1993 1994 1995 1996' <br /> A (multiply # by fee for <br /> C each year applicable) y <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 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 /> LL CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) ' X $159.00 <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 ..S150.00 = S <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) = $424.00 minimum Is <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TAHK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimm 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 = S 53.00/hr <br /> TOTAL DUE i S sri <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> xae wsxeoeaae.�ewe.mo.xeo»xoexe.xeaasxeaxewe xeeweeeeses7ewaP»ao.oawaa.wooxaeea xee xeeeexe.re.uwe`sae.�0000»e>»eo»xe.xea«xe.xe.�e.eewsxaao.zo«xeew»»»»x.Mexa.7ea.ee.x»�000.w..x.a.e xe.»ea xeee.ze.p <br /> x S . <br /> » s <br /> .......................... ....------------------.. .................... ........................ ..: ................. <br /> ... .... .......... J ........... .:R.r... » <br /> «� xXW� <br /> EH 23.032 iREv 1/10/911 ft Pace 11 <br />