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"SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> _ <br /> Ali co � M PM ZIP <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> I C WR <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P nn-- <br /> P � <br /> L �17Y�tPAN� J04 &roh <br /> I MAILING ADDRESS APPL CANT PHONE # WITH AREA CODE <br /> C <br /> A l I ft2K ET ST. SCO <br /> N CITY STATE ZnIP CODE TYPE of APPLICATION <br /> Y CLOSURE, INSTALLATION, eta <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUALFACILITYFEE (Prior to January 1, 1991) = $100.00 <br /> [ $ <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1 1992 1 1993 1 1994 1 1995 1996 <br /> A (multiply # -by fee for <br /> C each year applicable) S <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 (nicer amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) # TANK(s)_ X 5159.00 = S <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 9 TANK(s) X 5150.00 = $ <br /> P PLAN CHECK (Ins tall. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) = 5424.00 mini mm S <br /> 7 <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) _` X 5159.00 = S 131300 A r� <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = 853.00 per hour (3 hour minimum per facility = 5159.00) S <br /> M CONSULTATIONS _ UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S 3 gi <br /> OFFICE USE ONLY <br /> ........................_........q�...................................... .. ............................. ....... .. .......... .............. <br /> �•s....... .s", s .yx••�.n•. os «yyi ,ys .m�xov anf <br /> aGtEP5 a CF41" ldt" DISI-CCOE`�" AMOUNT"RCVO CAECX N/C`A5r�� RC O dY�"�`�i'l fe tc(�iE cR•R(, a <br /> _ ,.. i <br /> �.... ........O.L....... . L........ S ` .. . _..........s <br /> s... .....,. .s,,,. .i..,.>,.». ..e+.e....eeew.M.,,r, ....... .. ....... <br /> LA,v asnr«,mswnr,c�rmsa�e�ansamf,mucs>x�saw»�r.:�r.rnxinz'•,-'.m'=s,a•�`ra;s::,�:e.....:..">.....: .........:»^'x casxarsxar:../,a.,xsaarsixssr �'sawsa:sexaisaswuaoim'x <br />