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SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ' UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME <br /> F FACILITY CONTACT NAME <br /> I FACILITY ADDRESS <br /> ISIE PHONE �wi� AREA GCQE <br /> Y CITY 6 J) <br /> Sig TE ZI �E # of TANKS <br /> C% 741� at SITE <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE # WITH-AREA CODE <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T <br /> CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 !uv` <br /> i <br /> rG� <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991�K�jl9t p 5170/TANK (after January 1, 1991) !�'J <br /> F # Tanks = 1986 1987 1988 1989 1990 991 1992 1993 1994 1995 1996 <br /> A {multiply # ee for <br /> C each year applicable) �v j� rs) �� r <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 /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) <br /> 0 X $159.00 = ; <br /> S <br /> U TEMPORARY CLOSURE (A ane-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 - $53.00 per hour (8 hours minimum per Facility) = S424.00 minimum $ <br /> R REPAIR <br /> E TANK I.D. #(s) <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minimum/TANK) # TANK(s) X ;159.00 = ; <br /> A <br /> I <br /> R PIPING�REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) ; <br /> EFEE ------------------ <br /> ONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 00/hr FEE = $53.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> ........... <br /> ............................... «.........................,.........................,.......... . <br /> xoo wes xeoes mon weeas»oaeeeees»aozos wseaa eves aeaoa eeae- .................................. <br /> w�:xa. .y� r���'cwsa xea:=rc:a:sa:aNe xira:en+.r•+,: .;x,a.sz.,:;tao;r:a .;:�;;. .,. ... <br /> .1 CiMnJ ,y i0 mTIN':+0o-xl:xCO;L4EW%0»000:9p000%06100aee 14/Y X0000 i00>MOOPP bery ke0%9ro6%06%0 <br /> GCY Ot ` ' ai'�COba, -a .I:57: CODe• ' ...AMOfJN7R'CGTS:, .C.H..C'K...#JCiiSN;;t;r�TtC1/0}YBY <br /> ow X,. <br /> �rw^w:wrA c:ziew:;r.:r r;;o% •:.i;ta�+xte:;t%::ero;oni<e x%xaas+eae 7ocene eee zae oais iiia � <br /> ieaaioaaza..f <br /> Mn' etpC%RUd iAY A4�6A�f AOLbY%DK SbYF <br /> o.,n � <br />