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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY SITE NAME FACILITY CONTACT NAME <br /> A <br /> C <br /> I FACILITY ADDRESS <br /> L SITE PHONE # with AREA CODE <br /> a 9 - a <br /> T CITY S ATE ZIP CODE # of TANKS / <br /> Y <br /> at SITE <br /> A APPLICANT/BILLING NAME p_ ) AP15 PLICANT CONTACT NAME <br /> P <br /> L /� <br /> 1 MAILIN§ ADDRESS - APPLICANT PHONE # WITH AREA CODE <br /> C ?3 # c� a3y- o <br /> A <br /> N CITY / (\�' - STATE ZIP CODE ITYPE of APPLICATION <br /> T v� 5 OSURE, INSTALLATION, etc. <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> T <br /> 1 <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F Al Tanksx 850.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) <br /> 150156-1I <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 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> Y (enter amount and year) <br /> Sfo \ $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L CLOSURE FEE _ $90.00 each TANK # Tanks _ x $90.00 $ 11 <br /> 0 D <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 $90.00 $ <br /> P PLAN CHECK (Installation or Repair) <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 <br /> E $110.00 E <br /> P — <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan su 'ttal) <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 UE $ <br /> OFFICE USE ONLY J 0C -fees <br /> ............................ ..................... vJ 1....... ....... ...St, 1 Gv C' <br /> s ° ( 7 <br /> C7 <br /> g...................... $ g <br /> ....... ............................... ..... ....... ..... <br /> FH 23 032 (REV 61901 ft Pace 11 <br />