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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A <br /> C <br /> f FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L 1 r6 D� W <br /> I <br /> T CITY� STA E ZIP CODE # of TANKS -�_ <br /> Y -5 l� G 5� at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <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 /> TOTAL <br /> A <br /> C 1986 1987 1 1988 1 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> r <br /> l�lJ /oma /oo , <br /> 1 <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 19871988 1989 1 1990 1 1991 1992 1993 1994 1 1995 1996 <br /> A (Multiply 4 byby fee for <br /> C each year applicable) /ee I /Ro 1 /Ata 1 /Ov hp 5 <br /> I <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California N 8 S Code, Section 25287 <br /> 1 <br /> T # Tanks 2- x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amovtt and year) <br /> VL <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE - $53.00 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 8 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 5150.00 each TANK # TANK(s) _ X $150.00 : 5 <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 TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = 5 <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = S53.00 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 = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> s 5 a <br /> » a' <br /> AYAKRYOYMKGA%dKBYdY�:@iADIM AYfsYVf'�fr�Yb91#S9G]Y ?':AY3AY�lT.5�k3Y"SR?���:.Mi:in`."�,�Y:.:i::9;:>:•,:':#Y:L:.`D`.LYnCa:Yt�'ftY�WSi JS�Y 9ktY:DU�n%�a�utl l9�YilM s%ADl9tl�Y� <br />