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T <br /> SAN JOAOUtN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> E <br /> JA <br /> A kj •� ' Z Z <br /> C <br /> I FACT tTY ADDRESS SITE PHONE # with AREA CODE <br /> L i <br /> I <br /> T CITY STATE 2tP CODE # of TANKS <br /> Y it SITE <br /> A APPLICANT/BILLING NA4 APPLICANT CONTACT NAME <br /> P <br /> P <br /> a <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 /> t <br /> r <br /> TOTAL <br /> A <br /> { <br /> C 1986 198? 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) a $100.00 <br /> I 5 E <br /> V <br /> E TANK FEE • 350.00/TANK (prior to ,January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 0 Tanks a 1986 1987 1988 1989 1990 1991 1992 1993 1994 1445 1996 <br /> A (muttipty # lay fee for ' <br /> C each year applicable) 5 <br /> I <br /> L STATE SURCHARGE a 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T # Tanks x $56.00 1986 through 1990 1491 through 1996 <br /> Y (enter amount and year) <br /> 9 <br /> PERMANENT CLOSURE (Removat or Authorized Closure-in-Placa) TANK I.O. #(s) <br /> C <br /> L CLOSURE FEE a $53.00 per hour (3 hours Minion per TANK) # TANK($) X $159.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.O. S(s) <br /> R l <br /> E TEMPORARY CLOSURE FEE a 3150.00 each TANK #'TANKts) X 5150.00 ua 5 <br /> I <br /> P PLAN CHECK (tnstall. Ptan Review & Construction inspections) TANK I.D. #(s) ' <br /> L <br /> f <br /> A <br /> N PLAN CHECK FEE • $53.00 per hour (8 hours minimum per Faeiilty) a 5424.00 Minion 3 <br /> R REPAIR TANK I.O. #(s) E <br /> E <br /> P TANK REPAIR FEE a $53.00 per hour (3 hours mini TANK) S 1ANK(S) X 3159.00 a S <br /> A <br /> k <br /> trATME NT <br /> � <br /> R PIPING REPAIR REVIEW & CONSTRUCTION a $53.00 per hour (3 hour Minimum per fatuity s 5159.00) 5 <br /> Mcam <br /> ED <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION 1 9 SC FEE * S53.00/hr FEE a 853.00/hr FEE = S 53.00/ht <br /> r <br /> " ' ,HEALTH k l e"— )td'f ..rF. <br /> EN <br /> __'16dQ1191 fi U'0 3 <br /> TOTAL DUE 5 1 5 f <br /> OFFICE USE ONLY <br /> �,:i+»ai.«>;»iw�.iu.zw�.:x+."aw>swio�:»wMm.«,:im.aammsrmoaiixowt«t:ieeaaoivawei ix�sexii:naoa:"oosieeoao:ws»aw�o»miaes amw.�sie�ie x»»ea.w»a�s�meswsse«e.,:»io:::,"e»»ews,:»i..:iew�+uae xw. <br /> 77 <br /> : S ; <br /> / 00 <br /> csptasac�xss�# �saa-��xtss��srtAaxr s' saar�r,ax�c�aaacssox ;� <br />