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'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A `yl <br /> G <br /> I FACILIT ADDRESS SITE PHONE # with AREA CODE <br /> L �� .? J tom . ���� � C �� —• <br /> ) <br /> T CITY / [/ STATE ZIP CODE # of TANKS <br /> / tT <br /> Y—^ /I�Z /- r '� '-.. of SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> 1 MAILING ADDRESS _ APPLICANT PHONE # WITH AREA CODE <br /> G Pva <br /> A <br /> N CITY / $7A1E ZIP CODE TYPE of APPLICATION <br /> .� _ _✓ G"^ CLOSURE, INSTALLATION, etc. Lif .Ct �� r. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C —717 <br /> 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> T <br /> I E <br /> V <br /> E TANK FEE = S50.00 each TANK <br /> F 0 Tanks x 550.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) 5 <br /> I <br /> lSTA1E SURCHARGE = $56.00 each TANK (see CA HEALTH 8 SAFETY CODE, Sec 25287 for applicability) <br /> I # Tanks x E56.00 1966 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> Y (enter amount and year) <br /> E <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> C <br /> L CLOSURE FEE = $90.00 each TANK # Tanks x $90.00 E <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> R <br /> E TEMPORARY CLOSURE FEE = 580.00 each TANK # Tanks x $90 DO <br /> f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) S <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each SUBMISSION/RESUBMISSION # Tanks x 5110.00 E�3 <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, mim9 one hour to be paid on plan sutrnittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = S30.00/hr FEE = E35.00/hr FEE = $35.00/hr S <br /> TOTAL DUE E �� <br /> OFFICE USE ONLY <br /> Mi FY1 AXA.if11M:V MT MNH W(W%RA,N'Y�gY RN 9AIt ALAI :RW#Y KA6 k:o 3siY 9S6 W%N%M 61Xd AA M6!J>%a[N 0#�8t�� Yr RUt yb.NLV"9.i WHfW xM%AA)RVI%H 81RY R%PA R�.Y3R6M <br /> IN 23 032 (REV 6/90) It Pnac 11 <br />