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0 <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES / <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A �v Y/ki U14 Eph"-rR ca . <br /> C SITE PHONE # with AREA CODE <br /> I FACILITY ADDRESS <br /> I <br /> STATE ZIP CODE # of TANKS <br /> YCITY �itUOI� C� gcr .J at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L APPLICANT PHONE # WITH AREA CODE <br /> 1 MAILING ADDRESS <br /> C <br /> A STATE ZtP CODINSTALLATION, etc.TYPE of APPLICATION <br /> C <br /> N CITY <br /> CLOSURE, <br /> T <br /> TOTAL <br /> A <br /> C 1986 1 1987 1988 7989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 7991) = 8100.00 $ y'pV <br /> I <br /> V <br /> E TANK FEE = 550.00/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 fee for $ <br /> 27U <br /> C each year applicable) C7o 50 5U yU SD <br /> I <br /> L STATE SURCHARGE = 856.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 7990 1991 through 1996 <br /> Y (enter amount and year) �6 <br /> 5 6 <br /> owe <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X 8159.00 = i <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $750.00 each TANK # TANK(s) X 8150.00 = $ <br /> P I PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N [:p:L:A:N:cH:ECKFEE - 853.00 per hour (8 hours minimum per Facility) = 5424.00 minimum $ <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) At TANK(s) _ X $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = 853.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M EVALUATION SAMPLIN <br /> CONSULTATIONS UNAUTHORIZED RELEASE G INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE S <br /> .OFFICE USE ONLY <br /> .............................................................................................................................................................................................. <br /> ese,o+e wose,eeweoeee wee meerwe wowwaeewwmee xee ns,:vFee ac<c:<x.u.w .> r...eweww xaexw woe.ooe,eaeeweer weeee»»waeaezw ra.e weave xee xae <br /> » S E pS' "' `0"MP"�d O'L�`•.�.061 a IYST�C00E•,....,.:.AMCUNT..RC,113 CHECX�ttICAS rI _' 'R CiIU'"Y8Y"Y"' / E� ITER <br /> a g <br /> s 5 » <br /> g...................... ........................ ........... ........... .................................. .............................. . <br /> xa»www...»xwerxeexew»ro»mxaerx».uroxe:eexo:ue:auorwva :<,.aa w,ro neew we wovexae xoe,oesae,eeo waese ze..ease»,sieeeeweeneve,eeserseeneee <br /> ...• >""b�X..':.X>AY>i.`YG.�.NAlY A3NYR%R61Y <br /> .......:.�.:.:.::.>............. ........:..... <br />