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SAN 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 <br /> A v1l1L ti � <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> t m h <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y a[ SITE <br /> MA ✓'t e. <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P ' <br /> P /� ''Q E. Q <br /> L V MGrI)A0,_ <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> G& y Em b&rc aAyv 1: i�.L 0 9 - 4S! /55-1 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T 5 �M 796=9? CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I $ <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 app(icable) $ <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 /> $ <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) 17� X $159.00 !_X; <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R 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 $ <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 TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $53.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE _ $53.00/hr SAMPLING INSPECTION FEE = $53.00/hr $ <br /> TOTAL DUE $ ('`� <br /> OFFICE USE ONLY <br /> ....................................................................................................................................... <br /> . ......................................................................... <br /> woo weoxoeoo aao waao xoo oeowo xoo a000 oo-aoeww»ewe deed aoeoro owo eooew woo wro w.boe woo xooeo woe awes woo woe ewoee xeo.roeae wed aeoae e000 wawo woo wee eee000>ooe xaoeo woo e000ao eeeo 0000 weeoo deed 000wo 0000 woe»e000 oeooas woe dodo weooe iooa iaoe <br /> g" SIJ EPmS+" COwPIuT�r'If , %L'6rew" )�YS�' l 10' T CV`��zmt .C�`E'"/PA Nexus. %12EC ( ) Il zxAxsnx a E l � g <br /> awadoowwe>a.>oweowcowawwoewoowweew»aueoaxoweeoowoeowoeowaswoowwaowedwooeewe/W$ woo woe wooedwesweoeawoeweeooxaswoowwoewooweaeewoe00000e;veowoewewewoo>o�>eeoxwoeweewweo�wo>eoowowewoowoo <br /> %zac.•tr ra%tx u%mra?axz�x%uvszmx, zratraa:za�r%yt%mr %xx cxcar.�asxaraaOMW rm=arae=Z=xoi=a?ratxx%Marza%�W%ys�a"am � xex azsrzax tmaxs <br /> EH 23 032 (REV 4/8/91) ft Paoe 11 <br />