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S <br />t <br />T <br />E <br />A <br />P <br />L <br />1 <br />C <br />A <br />N <br />SAN JOAOUIN COUNTY PUBLIC HEALTN SERVICES - ENVIRONMENTAL NEALTN DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE YORKSNEET <br />FACILITY SITE MW <br />o <br />CITY STATE <br />IiNCS. 154 Cq <br />FACILITY CONTACT <br />/V S/ df7 (J <br />FACILITY ADORES! <br />L <br />SITE PNONE / with AREA CODE <br />3 0? Z N• <br />TOTAL <br />(-10 <br />CITY // <br />S T t 7'0 <br />1966 1937 1948 19" 1990 <br />STATE ZIP CODE <br />C/fi 9576 0? <br />0 of TANKS <br />at SITE <br />APPLICAN BILLING NAME <br />a 1624.00 minima <br />APPLICANT CONTACT NAME <br />C <br />G <br />TANK I.O. ICG) <br />NAILING ADDRESS <br />T <br />APPLICANT PNONE N wITN AREA CODE <br />83 's <br />1 <br />cl/' 393— I 1'e8 <br />T <br />CITY STATE <br />IiNCS. 154 Cq <br />ZIP CODE PLICATION <br />93-e� 9 Clooure Installation, ate.) <br />C /0's0 av-- <br />L <br />TOTAL <br />A <br />AMML FACILITY FEB (Prior to January 1, 1991) • $/00.00 <br />1966 1937 1948 19" 1990 <br />A <br />" <br />PLAN CNECK FEE + 178.00/hour (8 hours minlsumfFACILITY) <br />a 1624.00 minima <br />$ <br />C <br />REPAIR FEE (;;;;plan Review A Construction Inspections) <br />TANK I.O. ICG) <br />T <br />FACILITY PENALTY FEES ASSESSED (If Applicable) <br />XXXX )OM(i <br />1 <br />1 <br />TANK LINING REPAIR FEE a $78.00/hour q hairs minlsu vtAN)I <br />TANK(e) X 5234.00 • <br />9 <br />V <br />TANK FEE • 150.00/TANK (Prior to January 1,1991) <br />S17O/TANIC (After January 1, 1991) <br />mows <br />E <br />TANK RETROFIT REPAIR FEE a $78.00/hour Q hours win./FACILITY) <br />a $234.00 minima <br />0 <br />F <br />S Tanks ® 1986 1987 1988 1989 1990 <br />(autt(pty TVfoe for <br />1991 1992 1993 199: 199! 19% <br />A <br />each year appticebts) <br />• $234.00 minion <br />$ <br />C <br />TRANSFER FIR • $20.00 tIf1A nMMIZEO 29LOIASI EVAUTATtON • 178.00/hr <br />9 <br />l <br />I <br />TANK PENALTT FEES ASSESSED MM =(x <br />S <br />L <br />C <br />I <br />STATE SUMCNARGE • $56.00 a TANK Cow every 5 years) Soo California N i S Code, Section 25287 <br />1 <br />t <br />TOTAL DUE <br />1 <br />T <br />0 Tanks a 156.00 1966 through 1990 <br />1991 through 1996 <br />tenter t OW year) <br />$ <br />P <br />INSTALLAtION PLAN CRECK (Plan Review t Construction Inspections) <br />TANK I.D. #(a) <br />L <br />A <br />N <br />PLAN CNECK FEE + 178.00/hour (8 hours minlsumfFACILITY) <br />a 1624.00 minima <br />: <br />R <br />REPAIR FEE (;;;;plan Review A Construction Inspections) <br />TANK I.O. ICG) <br />E <br />P <br />TANK LINING REPAIR FEE a $78.00/hour q hairs minlsu vtAN)I <br />TANK(e) X 5234.00 • <br />9 <br />A <br />I <br />TANK RETROFIT REPAIR FEE a $78.00/hour Q hours win./FACILITY) <br />a $234.00 minima <br />0 <br />R <br />PIPING REPAIR FEB a 578.00/hour (3 hours minieWFACILItT) <br />• $234.00 minion <br />$ <br />M <br />TRANSFER FIR • $20.00 tIf1A nMMIZEO 29LOIASI EVAUTATtON • 178.00/hr <br />9 <br />l <br />C <br />COMMI'AfION FEE • 178.00/hr 1ANPLING INSPECTION FEE <br />• $78.G0/hr <br />1 <br />TOTAL DUE <br />1 <br />FOR OFFICE USE ONLY <br />EN 23 032 (REVISED 3-1-931 ►moa 11 <br />