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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> I '30 az <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y at SITE <br /> A APPLICANT ILLING 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 I CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> 1 /U o /uv /UV /Ud /lDv $V j j b® <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) �G Uc� 2t�v 6� $ <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 /> 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 = $ <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> [- <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 E.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 $ '26 2� <br /> OFFICE USE ONLY <br /> ..................................................................................................:............................................................................................................................................................. <br /> sw <br /> xooxoo-xoaaoxooxoeeo-eomazomao-xcammxaooaxaaxomoozoaxaaaexoo-x0000-xaoxos�oaooexao-x0000-xoaxaoexosxoa�ooeoo-xea�oo�o�eoo-xava000e�oo�000x�ocexao�000ao�oo-x0000-�oexo»00000�eeexo�o-�oo-�0000-�ooa�00000-xoo-�000-moee:xoo�000- <br /> S <br /> S.. oo- »eeexeeeo-�oo.o-.�e.e�.xoo$�000� �000�ooeoo ... ..........----------�.e.o.o.---... .................................... ............................................ <br /> xoImINo00:440. 000lace 14.1wx �xa............. <br /> a <br /> xemx�oaxop�ooeoxeoxoo-�000eexoo-xeeea�000-�ooeoemoa�000�xaoze�x000p�oxae <br /> EH 23 032 (REV 1/10/91) ft Paoe 11 <br />