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P <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) M I )&119' --, <br />0 <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X $159.00 = 5 <br />C <br />SAN JOAOUIN <br />COUNTY PUBLIC HEALTH SERVICES <br />L <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X $159.00 = S <br />ENVIRONMENTAL HEALTH DIVISION <br />PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) = $424.00 minimum <br />$ <br />0 <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />FACILITY SITE NAME <br />S <br />FACILITY CONTACT NAME <br />F <br />A <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br />C <br />$ <br />I <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />Ll <br />N t <br />I <br />TCITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />Y <br />at SITE <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />P <br />L <br />I <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH•AREA CODE <br />C <br />A <br />N <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />T <br />CLOSURE, INSTALLATION, <br />etc. <br />TOTAL <br />A <br />C <br />1986 <br />1987 1988 <br />1989 <br />1990 <br />T <br />I <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = <br />$100.00 <br />/0 <br />/ / 00 <br />/ <br />/ 00 $ <br />V <br />E <br />TANK FEE = 550.00/TANK <br />(prior to January 1,1991) $170/TANK <br />(after January 1, 1991) <br />F <br /># Tanks = <br />1986 1 1987 1988 <br />1989 1 1990 1 1991 1 1992 <br />1993 1994 1995 <br />1996 <br />A <br />C <br />(multiply # by fee for <br />each year applicable) <br />f 1� <br />I <br />L <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 <br />years) See California H & S Code, Section 25287 <br />I <br />T <br /># Tanks x $56.00 <br />1986 through <br />1990 <br />1991 through 1996 <br />Y <br />(enter amount and year) <br />�c fse <br />P <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) M I )&119' --, <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X $159.00 = 5 <br />C <br />I <br />R <br />L <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X $159.00 = S <br />N <br />PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) = $424.00 minimum <br />$ <br />0 <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br /># TANK(s) X $150.00 = <br />$ <br />P <br />PLAN CHECK (Install. Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X $159.00 = 5 <br />L <br />I <br />R <br />A <br />S <br />N <br />PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) = $424.00 minimum <br />$ <br />R <br />REPAIR <br />TANK I.D. #(s) <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X $159.00 = 5 <br />A <br />I <br />R <br />PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) <br />S <br />M <br />I <br />CONSULTATIONS <br />UNAUTHORIZED RELEASE EVALUATION <br />SAMPLING INSPECTION <br />S <br />C <br />FEE = 553.00/hr <br />FEE = $53.00/hr <br />FEE = $ 53.00/hr <br />TOTAL DUE <br />$ <br />OFFICE USE ONLY <br />