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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE <br /> S IIITTE NAME FACILITY CONTACT NAME� Seo Vol <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> 1 / <br /> Y LITY /� / / i / J ZEO atoSITENKS <br /> A APPLICANT/BILLING NAME ^v, APPLICANT CONTACT NAME <br /> P T <br /> Lit,C: <br /> L <br /> I MAILING ADDRESSAP LICANT PHONE # WITH AREA CODE <br /> C f. 0. be l0 D - / <br /> N CITY T CA <br /> ZIP CODE TY f APPLICATION <br /> T �� OSUR INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1 1988 1 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I S <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply ## by feefor <br /> C each year applicable) 5 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amovit and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) # TANK(s) X 8159.00 = 5Jr �- <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 = E <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = S424.00 minimum S <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = 553.00 per hour (3 hours minimum/TANK) # TANK(s) _ X $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR FEE = 853.00 per hour (3 hour minimum per facility = S159.00) E <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE s <br /> OFFICE USE ONLY <br /> ... ............................................................................................................................................................................................................................................. <br /> xo.:o:wee:.,efeeee.=...ease.w�.:see.eeeeae.gee.:eoee�e=eee>»e.ne.oeeee=e..eoe.:..eeee.=ee=ee»gee..ee.see..e..eee.:e.ee,..x.e�.=.....wee.»eeneeee,eeo��,.w.�.se.»e�eeee.=senses.=e.,��..o.=.. <br /> ma�uS tEr S `�`7=7=27"' <br /> 0 = SOL ' °'"S 'C c <br /> 11I_!.1. . ........ 5l.. ......! ..!....... _3a .... $...a.. ................. ...1.l... ......... .... .....�z................ .. <br /> .. w . www . w w . ,. ww . .... . w , YL .. b . . .. w . .... <br /> EH 23 032 (REV 1/10/91) ft • Pace 11 . <br />