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SAN JOAOuiN COI...a rY F1UBLIG HEALTH SERVICES-C—NVIPC)N..._.4TAL HEALTH DIV010N <br /> _ UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> • <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 4 44-1;,� <br /> FACILITY ADDRESS . Sl POONE*WITH AREA CODE <br /> CITY STATE ZIP COCE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING SAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING dR55S APPLICANT PHONE t WITH CODE <br /> t�.� .�.''- 3. 3 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> �R�'✓ ���0 1-*7' ...-• Closure Insbllttion Repair . <br /> ACTIVE FACILITY <br /> 1995 1996 1997 1996 1999 X000 <br /> ANNUAL TANK FEE IS 517D PER TANK $ <br /> TOTAL TANK i•EE <br /> T- <br /> $170 X #cf TANK5 X #OF YEARS APPLICABLE)I ( $ <br /> TANK PEN4LV AMSSED <br /> Tl SURCHARGC e$6/TANK <br /> STATE SURCHARGE FDR FACILITIES NDT QLRr�.DY ON INVENTORY IN A CUPA PROGRAM=5101 FACILITY <br /> PERMANENT CT SURE <br /> Removal or Permitted Closure in Ptace) � <br /> TANK 10# s ' CLOSURE FEE=5234!TANK #TANKS X$2311 <br /> TEMPORARY CLOSURE <br /> Plar, RavleW and In! Kdons) <br /> TANK ID#(E)' TEMpORARY CLOSURE FEE o 5234/FACILITY <br /> IN5 ALf ATZON PLAN CHECK <br /> Plan Check and Construct on ins eco <br /> TANK 10#(0: PLAN CHECK FEE-SE24 1 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID 0 s): $ <br /> TANK LINING REpA1R FE •�E 5234 TANK #T�MIKB X S234 <br /> C26 ilIlIll <br /> TANK RETROFIT REPAIR F'ce -$234/FACILITY g <br /> PIPINd REPAIR FEE =S234 J FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE = 57B 1 FLOUR � <br /> CONSULTATION FEE - S 7S/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE S 78/HOUR <br /> SAMPLING iNSPSCTION FIRE = S 781 HOUR <br /> ALL FEES ARQ ED ON E$78 H URLY RATE, 7184E THAT 4:7GG!<EDS! S PAIg WILL 6E BIL Q APPLICANT. <br /> oFrici; USE ONLY <br /> st;RVlCtr REQUEST>x FAGS-1T ID AMOUNT RacEIYE❑ CHECK tt iI RECEIVED BY DATE REGEIvao <br /> S/E'd 9E8.ON ` 00 110oS I WdS2:E `z002'Eti 'H3 _ ,_ <br />