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SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />. , UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />TOTAL <br />A <br />C 1986 1987 1988 1989 1990 <br />T ANNUAL FACILITY FEE (Prior to January 1, 1991) a 5100.00 <br />I S <br />V <br />E TANK FEE = 550.00/TANK (prior to January 1,1991) f170/TANK (after January 1, 1991) <br />F 0 Tanks ) 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />A (rtultiply 0 by fee for <br />C each year applicable) ,�_I I— $ —\ (J <br />1 <br />L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />I <br />T I Tanks ,-1 x $56.00 1986 through 1990 1991 through 1996 <br />Y (enter amount and year) <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />r' <br />A <br />S i —` <br />0 <br />C <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review b inspections TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK 0 TANK(s) X $150.00 = <br />S <br />I <br />FACILITY ADDRESS <br />SITE PHONE 0 with AREA CODE <br />L <br />T <br />CITY <br />STATE <br />ZIP CODE <br />I of TANKS <br />Y <br />at SITE <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME_ <br />P <br />�\ <br />I <br />HAILING ADDRESS <br />APPLICANT PHONE 0 WITH -AREA CODE <br />A\ <br />,c�_� <br />N <br />CITY <br />STATE <br />ZIP CODE <br />TTYPg-of APPLICATION_ <br />T <br />c� <br />,= <br />_ <br />,�� ' ri C�` <br />CLOSUR�t;�INSTALLATICN, etc. <br />TOTAL <br />A <br />C 1986 1987 1988 1989 1990 <br />T ANNUAL FACILITY FEE (Prior to January 1, 1991) a 5100.00 <br />I S <br />V <br />E TANK FEE = 550.00/TANK (prior to January 1,1991) f170/TANK (after January 1, 1991) <br />F 0 Tanks ) 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />A (rtultiply 0 by fee for <br />C each year applicable) ,�_I I— $ —\ (J <br />1 <br />L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />I <br />T I Tanks ,-1 x $56.00 1986 through 1990 1991 through 1996 <br />Y (enter amount and year) <br />S <br />P <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. "(s) <br />C <br />L <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) S TANK(s) _ `, X $159.00 ■ <br />S i —` <br />0 <br />S <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review b inspections TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK 0 TANK(s) X $150.00 = <br />S <br />P <br />PLAN CHECK (Install. Plan Review b Construction Inspections) TANK I.D. R(s) <br />TANK I.D. 1(s) <br />E <br />P <br />L <br />I TANK(s) X S159.00 = <br />S <br />A <br />N <br />PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum <br />I <br />R <br />R <br />REPAIR <br />TANK I.D. 1(s) <br />E <br />P <br />TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) <br />I TANK(s) X S159.00 = <br />S <br />A <br />I <br />R <br />PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = S159.00) <br />S <br />H CONSULTATIONS <br />1 <br />S <br />C FEE = S53.00/hr <br />OFFICE USE ONLY <br />a <br />Aff ]Ef ffafX 9rT A� 9917 AI.'K AM <br />UNAUTHORIZED RELEASE EVALUATION I SAMPLING INSPECTION <br />FEE = S53.00/hr <br />x''C00 xUIST"CODE AxUN7' i2C'�I" <br />FEE = S 53.00/hr <br />TOTAL DUE S 1 <br />"•�:N :4wf :!M.C6 !iA \:".:.KM: t..bRf. I(e.:Otti1 M� IM�:VMY MM YW. fY. ]YA. 1M. �eM.IM� Irk IMM. lW )Y. <br />CnEC1C"�ICAsi C`D�Y3fa�k r CTcI/E�` 1I AlmaAaxAT <br />a <br />m`:i::w51:"Y «:s:",SY l"^•.YS :': 9.s ==)W IDT 99AIA 9W AMW WX NOW ASA AYM Ani gut X" 9" Rot <br />