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SAN JOAOUIN CGUNTY PUBLIC HEALTH SERVICES <br /> ENVIRGNMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> c T <br /> I FACILITY ADDRESS SITE PHOIlE 0 with AREA CODE <br /> T CITY � STATE YIP CODE a of TANKS <br /> r at SITE � <br /> A APPL ANT/STLLING NAME A PLICANT CONTACT NAME <br /> P <br /> P - <br /> L <br /> 1 MAILING ADORES D APPLICANT PHONE R WITH AREA CODE <br /> C /(�/-tel <br /> A <br /> x CITY STATE zIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> 1 ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100 00 <br /> I s <br /> v _ <br /> I�IV�q�ll � ��MNT CMpA �• T 6,8 <br /> g <br /> . RM r fr 1 , <br /> A GOMM RRIf`xt60ANY 1•a!` 1 '� " t ,�! ' ,,� � : �,�� r <br /> Otpr9 0-2��.�341�+�r`'�•1 .fir �M� �► .2''�J .. <br /> S+; O6§t1d/1222 <br /> 441' � / C./ t + • �� <br /> A. <br /> Tip <br /> aY • — t t <br /> 1+606 LA vA2 ORtV!VIC1bAJN1�C1lLrtoAHIA If4l� +�- 1,�✓ <br /> iI'dd�g a rlpa �. � ' t]�i:C] 100 2 00 11110 t ' <br /> N PLAN CHECK FEE - 153 00 per hour (8 hours minimum per Facfifty) - 1424 00 mfnfalum ! <br /> R REPAIR TANK 1 0 !!(s) <br /> E <br /> TANK REPAIR FEF $53 00 per hour (3 hours minimum/TANK)' N TANK(s) X $159 00 = t <br /> A <br /> 1 <br /> R PIPING REPAIR REVTEV I CONSTRUCTION m $53 00 per hour (3 hour minimun per facl(ity = 1159 00) ! <br /> IN CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 5 <br /> FEE = 953 tltl/hr FEE = $53 00/hr FEE 1 53 00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> r.+.a i..a r,..,,a Mea.waw+..v u.r• wn►rea-ar a,v a�rte<a�w� nx'rwi»-.. a<i aro <br /> >TI �' Ars•COT i il YrST11'7 <br /> Y 16 <br /> <.. .<•1 a 's <br /> ��>Aearw>ra w.....w rwwr�+....•+..�.� .7l A1Y s'!r <br /> S E 'T r ` EOug,h Y "') CibE10 <br /> v" /�jU117 1011 IEC{/KCA I �) BY T`rI9RIF MEr 'T rI R <br /> '•may>✓•ww.w xWM •tfYa W.aw♦r <SP Ytpq�o to 1rI AAy w•1 awry Ma w�a aw rntw <br /> n aKff m i'Pllrl All ra[:4Y 1E7 R fge3r 2iY lYiL'J Is'.Y Ai^.'..Y)7 �J f.Y »7:.5,^,"Y:'{ `;.„Y• " ••^>•q Y„ k? S..K^ f Z t�lY"J,,,i " r_-r+.tial rUY�i7 70Y W7Y/WR RtsK 1W Aligl tai r�}J3Y»QX AW <br /> d 71 n17 rare 17/7A/Ohl ft Pena �1 <br />