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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISICN <br /> iDERGROUND STORAGE TANK PROGRAM - FEE WORKS <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A L�K�Fp2� 1591 AV <br /> C <br /> 1 FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> I 2i oo/ /U, ��r o /Qo�d� 269• �Z - 3 2 o s- <br /> T CITY STATE ZIP CODE At at of TANKS 2 <br /> Y 4oc�E�ol2D 9523 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P5�/n G� <br /> P A/L7 <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C 413/ �- 7" �D� Za9 SZ X653 <br /> A <br /> N CITY _T6 916- <br /> ZIP CODE TYPE of APPLICATION <br /> T /itw� 7_6? cmc 916-3 � CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I $ <br /> V <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) $ <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> 1 <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 a $53.00 per hour (3 hours minimum per TANK) # TANK(s) Z X $159.00 = f 8 D O <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 $150.00 = f <br /> P PLAN CHECK (Install. Plan Review 8 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 S <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> — <br /> E <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = f <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 /> 1 <br /> S <br /> C FEE 553.00/hr FEE - S53.00/hr FEE = f 53.00/hr <br /> TOTAL DUE 5 !31g'06) <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> ww woo waa ww www wa waw ww ww w000eww woow woo w0000 wee woow ww ww we000 ww we000 ww woow woo wa www zoe wow.ww www ww www ww woe waw woo www zoo www ww ww woeeo woo wowo ww www ww www ww ww weew woo ww <br /> MIM E ' `o <br /> $3i�.v� c,xx ow �- <br /> w»ww waw ww wawww wawww ww wa»ww waw w»waww»waw www»waww»w.a.wwwaww»w»waw ww waww»waww»wew.we.ww waw w»ww»ww waeowa ww wwwww w.a.ww Aaww»weew w»w»ww»w»ww <br /> EH 23 032 (REV 1/10/91) ft Pace 11 <br />