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i SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> EN'I[RONMENrAL HEALTH OIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE UCRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A eek-P-1 <br /> 1 FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L ! 1 r �y <br /> T CITY STATE ZIP CCOE if of TANKS <br /> r A � at SITE ., <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P t <br /> P <br /> L <br /> I }AILING ADDRESS APPLICANT PHONE S VirH-AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CCOE TYPE of APPLICATIQN ' <br /> T CLOSURE, INSTALLATICH, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> TANNUAL FACILITY FEE (Prior to January I, 1991) _ !100.00 <br /> I <br /> S <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # ranks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) _ � $ <br /> L STATE SURCHARGE v 556.00 each TANK (Due every 5 years) See California H S 5 Code, Section 25287 <br /> l <br /> T # ranks x $56.00 1986 through 1940 1991 through 1996 <br /> Y (enter amount and year) <br /> $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK 1.0. 1(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) Al TANK(s) X $159.00 a $ <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d inspectionsETANK I.D. N(s) <br /> R <br /> E TEMPORARY CLOSURE FEE a SISO-00 each TANK NK(s) X $150.00 $ <br /> P PLAN CHECK (Install. Plan Review d Construction inspections) TANK I.D. X(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. x(s) <br /> E <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minimum/TAHK) $ TANK(s) X 5159.00 = S <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW b CONSTRUCTION = $53.00 per hour (3 hour minimum per facility a $159.00) S <br /> N GCNSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE _ $53.00/hr FEE S53.00/hr FEE = t 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> ....,.,.. ....... �S ;aw.:n.:..wx..:�:. . .You: ..w...a►:u€.xAc. wN,u.Mb.xa ...... wxw..:�`w:; ;.:►.. ......-- :--:: .:— <br /> V€cra ' ODI '" LDC'cO}�.. �}tST'c'cae , ablci7irl"RC',v C4C19-70SH <br /> r <br /> LIN <br /> MW <br /> w►��ii:imi:aii:ra•:iicw^a:'i..••xt�i atv�s:as iw_u ... .. •-.•• -•,• •••••..-^•• •••••••••• _ __ <br /> r�aigq�s=i�R.#:MflYl��ai AV.S!{'Y dffi7.l'35Y:: "Z::RLS':.itM.T�:`W:::'i"':w..«.....e......,rV:.,"s+i�f est-n%�<ri.:c• n ai!.;.i... ..r.r.sw.i:war:�•••••••••••�;�w:,;w•••._,;:;. <br /> MW M/fl{ .71M'.Yr1S.p4 <br />