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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISICN <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A S l�S Z) - <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y 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 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I $ <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 3170/TANK (after January 1, 199 1) <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 /> I <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> � S <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) X $159.00 = 3 <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 3150.00 = 3 <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 TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) TANK(s) X $159.00 = 3 <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $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 = 353.00/hr FEE = 353.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE 3 v , <br /> OFFICE USE ONLY <br /> ....................... <br /> Xoo ww x<000XDD x0000>)eo xeaoo>000 xao x000D,000:aDX•xwX<::o:<!o:«+,:�.c>;:a:!!.:<:,:•>»>:<.::.> > ::::.;>:.:.:.:::•:c;:c:.;:.�.:;.;:. . :.:�:.»>:�;:�;;;:�;>:�:<�>;:.<.:. o.eo.a.;e+oee x!n>rreoww X000>i000 ioeeee eoe»ww ieee <br /> g �•>Xa rvc. ...X..,.•::)':1:>,Y::.`.;:..,,y... �.:::.>:!•:<.:.::.:;i;>:::<;::..;i';,.::::. f:�:� �..�y...:'^'.i:.? rti � <br /> S IEi Psi "coMl t#zw oC i:Coo tiIST cCT3E alaouN4 R0'* CnECK' CASrI ' �C`1ti BY I drip Ettl <br /> � CeKIT G l 3 <br /> . .......... ........................ ........................ . ....;............. ........................... . <br /> %0>bI010000O X00%OW>>00>%0000%00 J000%OMO!OCO%0000)DOD XO!dO:fSP:K<4):!. :!!<O:HiJ:<•>:M>Xn;!•::^i;:V.•'+.::ti:!•.:•:!:+i:iii:?:H.:.:!ry}:n vvn);.v,!?i:!!•::A:!K<O:f!G AO:00000X00%OOJO000O M00 bW0>%0�>1o00�fOM J000M)000)00060000%00%00 <br /> «ati 2,LY> 5«917DY1>�Y f 02i1 R5l A 'eYl AbYJf SI.Y>Y.7.Y:SJS>`J+`i:«:)i.if:.'.':>.54.2•Y'S:':Y:S: :`."S Y^?Y^::�::":i;>.ii i):i i:S; :;::'R:;':+'.`Y ii:: w)Y J.)f:.a,.,is 9.»>'r.>".CS>Ydl R'LD�I rYOI AD'oDU mUC 7DbW6%U6 AO�Jfl>YX foLD'DY> f <br /> cu xZ nz� tDCV 19/;PF/9n1 ft Pnae 11 <br />