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SAN JOAQUIN COUNTY AUBLI <br /> ENVIRONMENTAL UULIC <br /> F FACILITY SITE NAME HEALTH <br /> HSNRVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> A FACILITY CONTACT NAME <br /> I FACILITY ADDRESS <br /> I SITE PHONE # with AREA <br /> CODE <br /> T CITY n <br /> STATE ZIP CODE <br /> A APPLICANT/BILLING NAME — at SITE <br /> # Of TANKS <br /> P ., .� �. <br /> F, APPLICANT CONTACT NAME <br /> L <br /> I MAILING ADDR SS L <br /> �. <br /> / <br /> C `f �;j <br /> A } Com' APPLICANT PHONE # WITH AREA CODE <br /> N CITY <br /> TYPE of APPLICATION <br /> CLOSURE, INSTALLATION etc. <br /> ANNUAL FACILITY FEE '° <br /> A (prior to January 7, 1997) = 51p0.00 <br /> C <br /> T TOTAL <br /> I 1986 1987 1988 1989 1990 <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) $ <br /> 5770/TANK (after January 1, 1991) <br /> 989 <br /> F # Tanks = 7986 1987 1988 1 <br /> A (muttipty # by fee for 1990 1991 1992 1993 <br /> C each year applicable) 7994 1995 1996 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due ever 5 $ <br /> I Y years) See California H & S Code, Section 25287 <br /> T # Tanks x 556.00 1986 through 1990 <br /> Y (enter amount and year) 1991 through 1996 <br /> 5 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> C TANK I.D. #(s) <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /> 0 # 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 = S150.00 each TANK # TANK(s) X $150.00 = <br /> S <br /> P PLAN CHECK (Instal(. 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 5 <br /> REPAIR TANK I.D. #(s) <br /> R TANK REPAIR FEE _ $53.00 per hour (3 hours minimum/TANK) <br /> E X $154.00# TANK(s) = <br /> S <br /> P r <br /> A- PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility) = $159,00_. <br /> R MISCELLANEOUS EVALUATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> (when applicable) (when applicable) <br /> FEE = $53.00/hr FEE = 553.00/hr <br /> FEE = 553.00/hr $ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> ........ ... <br /> xwbaew000xco oaoo xaexiooaxoexeo-woacxoswowa»ooxaowzoxouasxaa cwwo o zewa4w ca4izoea«a u e aoaao wo-a itw"waeexiyl• xaa Wow.... a aaoawoesvAw add o0o eaeee eeei0006o aaebeeeo�oezoeoo-o oeo o- <br /> ''CN`7`01CrH` A � <br /> ... ..... ,.. ... ..... ... ............. .. f <br /> ......... ................ ........... <br /> EH 23 032 (REV 12/26/90) ft Paae 11 <br />