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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICO <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAM <br /> P '?�C17 <br /> A <br /> C SITE PHONE # with AREA LODE <br /> I FACILITY ADDRESS <br /> L a 00 © # of TANKS / <br /> I STATE ZIP CODE at SITE <br /> T CITY <br /> Y c\�1FL.(I/1 <br /> APPLICANT CONTACT NAME <br /> A APPLICANT/BILLING NAME <br /> � <br /> P <br /> L APPLICANT PHONE # WITH AREA COD <br /> I MAILING ADDRESS / <br /> C <br /> A STATE ZIP CODE TYPE of APPLICATION <br /> T CITY _/u �� ,/l g511 — CLOSURE, INSTALLATION, etc. <br /> G�i_M. ./��V V w ,'l _l•J TOTAL <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> A 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> C $ <br /> T <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F # Tanks_j_ $50.00 <br /> A (multiply # by fee for 0 <br /> C each year applicable) �J <br /> I <br /> FETY CODE, Sec 25287 for applicability) <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 8 SA <br /> 1 <br /> 1992 1993 1994 1995 199 <br /> T # Tanks x $56.00 1986 1987 1988 1989 1990 1991 $ <br /> Y (enter unt and year) 5 /_ <br /> PERMANENT CLOSURE (Removal or Closure-in-place) �P E <br /> C # Tanks x $90.00 <br /> L CLOSURE FEE _ $90.00 each TANK <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (Only allowed one time for up to two Years) $ <br /> Tanks x $90.00 <br /> E TEMPORARY CLOSURE FEE _ $80.00 each TANK <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = E30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) $ <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each SUBMISSION/RESUBMISSION # Tanks <br /> x $110.00 E <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan sutmitta ) <br /> 1SAMPLING INSPECTION <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION (when applicable) <br /> (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE _ $35.00/hr <br /> FEE = E35.00/hr E <br /> TOTAL DUE E�6 <br /> OFFICE USE <br /> g....'...fi.................. ONLY8Lc ............ ........... ........................x......w....... <br /> .......................... .. . ........ <br /> .. ........... .................. E� ..R............° <br /> .... . � (�I " TXTT <br /> ds ........a.. <br /> ww � xww� <br /> 19 <br /> a <br /> ........... <br /> .......... ............ ......... <br /> FH 23 032 (REV 6/90) ft Pame 11 <br />