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SAN JOAOUIN COUNTY PUBLIC HEALTH SERYP <br /> t4 ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE ttot T <br /> FACILITY SITE NAME FACILITY CONTACT HAMS <br /> A <br /> LCiC <br /> I FACILITY ADDRESS / SITE PHONE # with AREA CODE <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y S��b �!Z CK-CT 1 at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P n, <br /> I MAILING ADDRESS APPLICANT PHONE # WITH 4REA CODE <br /> A <br /> H CITY STATE ZIP CODE TYPE of APPLICATION <br /> T C CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I <br /> Y - I <br /> is <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE a $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> I <br /> T # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) TANK I.D. #(s) <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = S <br /> 0 <br /> S <br /> a U TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.D. #(s) <br /> R <br /> E rTEMPORARY CLOSURE FEE _ $150.00 each YANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (install. Plan Review b Construction Inspections)j TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facility) = $424.00 minimum S <br /> R REPAIR <br /> E TANK I.D. #(s) <br /> ' <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R P11 IPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = S159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> t <br /> S <br /> C FEE = $53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> �p��. q�y(•�^y :K.:OY:OM XKNe'OA+CNiO:pC4.............................� 8S:....}'!!N@%i4 ti.Y N"q'`4p M0 ••• <br /> b �K6J N WrE pr ;:'�•!wrww....w'; 'w.,.,l :•!C«?Y 4 4.^v^j.'�"'� %. 'RCe%ee..,`a'"s':<el AM xew>M"f 1MUM loM Aw"s'l1M iMMfNSMM'x"M'MM <br /> tfitirsr c�f)E aiaDtiNfV ii'culi' 'CifEGi(`'' casii'� �vb `B ' dr "IdE ""'W" tI' ' " <br /> SIM I4mRlf�ksw@ MMNOp„0lINOPS M►MIN MM%@Oms:pM%CK@%N:6M%MM:44@%Y.M:LS@'K!SON@%M%5!s7%+@.'@Y.}D%!@.t@R'@%!@!T%!O}%@:Ste:utN XII iOCIM MPAaeI NW%NIMH Ml7101es � «• '{ <br /> ca 71 nip /ocv 1p/pA/9n1 ft P�oq 11 <br />