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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A //Q6C <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE \A/1RONMENTALH <br /> oF�,'`'JITr SER�/V <br /> 1 <br /> L /-3 S. Gc'i/sor- �/6 - 3 6 3 - G /o <br /> T CITY / - STATE ZIP CODE # of TANKS <br /> Y S1Z7GlG�r9� q4�/v� at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> G 4/G/.? 'e" e' l�/�/ �v`moi z lurn�s G9 9 5 <br /> A <br /> N CITY STATEZIP CODE TYPE of APP /LJeu� /S�GH�/ <br /> T f�0i1�-t ��G(yv CLOSURE, INSTALLATIO etc. eK k�asi�� <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> T <br /> I $ <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F # Tanks x $50.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) $ <br /> I - <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 8 SAFETY CODE, Sec 25287 for applicability) <br /> I <br /> T # Tanks x $56.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> Y (enter amount and year) <br /> R <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> C <br /> L CLOSURE FEE _ $90.00 each TANK # Tanks x $90.00 $ <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $80.00 each TANK # Tanks x $90.00 $ <br /> PE <br /> HE (Installati or Repair) <br /> L <br /> A <br /> NHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) $ <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each SUBMISSION/RESUBMISSION # Tanks x $110.00 $ <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 1 <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE E <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> )OCO NOD b10001000%0001 700>�OWO)000%00�OWO>700D%OWO k00%OWO%001000001000)000)00000)OOO M0000)OOO biWD)004%00%00017000%0000]OOD%OWO )OCO k00 b0000%00100000%OO)OOOOO b00 b00)000OO b00»0000 SOD b00001000 b0000 bG0%00701106 bOJ 1000 <br /> `TF -FAmr, WRAP JC I rrn`"I WAR'E(i'v " . WN`I€fi it F;`M li <br /> 21 <br /> .. ro.l...... /�iPCDAU/. ........©. .... 3......... .$...& .....`y.... .... a...y w�l....... ..... ! ` ... ............................ <br /> )dA l;m)fa%O)000%ON01000]OOOC>70007000700000)000 N0000 7000 700000 7000 7 SOW 700000%0070P%O kA0�000P>OOD)000%00001000)00000]W0700000700P»cJ007000 N00K N000%00)00000)0007000 k0000700070000>N00>OWO>N0070000070007000700000 <br /> %:6 fK%?f90'6%Q6 Ao1dQ6%d6 7 7W6 fea%%6%6%fd ' fitl6 fAK%A0.%1 YtlG P%SSE fF16 tFf6 R'1Aof�AW11LN%d fPf6 Sd5'%6%N{Ro16%J�f A1.2�f6F1%elf%t. .K0'3f 721%Rkid f:4d R1%9Sb%%%Akt07�k0'6 A4Gi%lR76 AQ�PS A{d Ak.%:::^5.:0%% <br /> Fit 23 032 (RFV 6/90) ft Paoe 11 <br />