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0 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 f�r <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> I <br /> STATE ZIP CODE # of TANKS <br /> T CITY <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L APPLICANT PHONE # WITH-AREA CODE <br /> I MAILING ADDRESS <br /> C <br /> A <br /> N CITY STATE ZIP CODE =TYPEAPPLICATION <br /> T INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991). _ $100.00 <br /> I IUv /Uv /v0 ivD /ov $ ova <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) $ 7�U <br /> I <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) `r� <br /> ! b $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) I 2-4 i <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.Q0 = $ — !b�c ,� <br /> 0 d[sc osvi1 <br /> S alre l <br /> u TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.D. #(s) 'h <br /> R !�{ � <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK # TANK(s) X $150.00 = s <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) = $424.00 minimum 5 <br /> R REPAIR TANK C.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = <br /> A <br /> I 5 <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE = $53.00/hr FEE = $53.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE 5 <br /> OFFICE USE ONLY <br /> ........................ ........... '.••,,....-..:•.•;.;;.:y:'.:..i:i: ':n.'-:.:::: ::.�:.:.:+Y.-:.?YC4:tl?Li4:SN YCF4a;aao%oP:d000F W'W MOOPP%CP)0009Di�]Ip904]OOO iaO»wao }OOp <br /> HOa XAa1CaC,a 1000 NWba]OOa kMka}DOa NOP MCOOa SOOP Aa1W]OOa%s Va:eea Y:aw\Ya•ra e Jav oa9.r ?.::::::v.�::., •. r:^••`.;5S� �Y ..��r]SS <br /> g <br /> LaC"Ctio '� 1757 CGi7Ew A 10U} T:: `CdD +E CK"#/CAIN RC [S gY Ire?l Ew I <br /> $ » <br /> 9f.. xaaxw wmaa»ocweaea»eaxam:as 7eea:.•>xea:un;tcc:rax??u+:e:" :.:�.: <•:a:?<+.-xn Maio wa%i tea. +eeeee iwaizo zowoawo-:aeeoe»ee ia'aeesiae>ioweaieeszee z0000 iooe:ear <br /> >7F91S&%ie3E91 iB% >'a�RpJ3K�l RMl �!X f�Y.Y S7.YAL7A'iY?Y'hY'3.Y i;.r::.,:`f.-.:?rY: <br /> CU '27 n:l) .Cu on, C. <br />