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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UN ROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A -oil <br /> IFACILITY ADDRESS �� id, ������5 SITE PHONE # with AREA CODE <br /> T CITY ��� � ��� IATE� 2IP CODE /e10 of TANKS <br /> t SITE <br /> Y <br /> A APPLICANT/BILLING NAME - APPLICANT CONTACT NAME <br /> P <br /> P �j[�/✓I Gv <br /> L <br /> 1 MAILING ADDRESS / �, //��C 71,9APPLICANT PHONE # WITH AREA CODE <br /> Y r �9. sz� • �bs3 <br /> N CITY NM1 S��A1TE 2IP CODE TYPE of APPLI GTION n� <br /> T /720.0 us 7O 'tel- 5 CLOSURE, INSTALLATION, etc. (J 60ooAL <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I S <br /> V <br /> E TANK FEE = S50.GO/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 (m Ltiply # -by fee for <br /> C each year applicable) <br /> I S <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> 1 <br /> T # Tanks nx 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amat and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> minimum FEE - $53.00 per hour (3 hours minimper TANK) # TANK(s) X $159.00 <br /> 0 $ /C O <br /> S J <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 = $ <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facility) = S424.00 minimum $ <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) _ X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour mini mm per facility = S159.00) ; <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE - S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S Z'QQ <br /> OFFICE USE ONLY <br /> . ..... ........................................................................................................................ <br /> nwffe ras <br /> �wmrrss�rrrrrrressiw�wr+eerwisrsrnr�aerwwarrrwrswwr,�r�erraeswrr#we�wrwa'wairsur"""irieair+saisir`siraias <br /> EH 23.032 (REV 1/10/911 ft Paas 11 <br />