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4SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F �t i <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> I <br /> T CITY STATE IZIP_COD E # of TANKS <br /> Y � j 1-4 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 /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1 990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I 4. p $ �Dv <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 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 (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> N Yo <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) 17' <br /> C <br /> L CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = $ <br /> 0 <br /> S <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 & 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 $ <br /> R REPAIR FEE (workplan review & 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 = $ <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE _ $53.00/hr FEE _ $53.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE $ <br /> (7 <br /> OFFICE USE ONLY <br /> woo woo w0000 zoo b000a woazooeo weo woa we000 boo waw zoo-woow woo we000woo-wea zoeoo woo w0000 woe wwao zoo-zoo-w0000 zoowaeo wroxo00o woo-z0000 woo woo weoao zoo zooao wea wooee z0000eowaoen woo-wooro zoo z0000 woo-wa000 zoo-woo-w0000 woo zao <br /> ss o `sc LX AIM%x <br /> $ <br /> g.......................... ........................ .................... ... ................. .................................. .............................. .................................... ........................................... <br /> woawoawoo�woo-w000awoo-woo�w�w�w�wodw000awoawo�w�woo�r .0000aw�wo�woowo�w�woo-w�w�w�woo-w�w�w�w�w�woo�w» ,w�w�,w�w�w�,w�w�woow0000woawo�woo,o�w000bwoo-,00a <br /> EH 23 032 (REV 1/10/91) ft Pace 11 <br />