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JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> I FACILITY DDRESS SITE PHONE # with AREA CODE C <br /> T CITY 7STAT�E ZIP CODE # of TANKS <br /> Y S�7C at SITE •, <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P 7-7� <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> A <br /> N ITY STATE ZIP CODE TYPE of APPLICATION c <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I $ <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) _$170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1 1988 1989 1 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) f <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = f <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum f <br /> R REPAIR TANK I.D. #(s) <br /> E <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 PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) f <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr T FEE = $53.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE cJ <br /> OFFICE USE jQNL-'Y_ <br /> yy[�^'' :........................................ ............:..... ..................................................................................................... <br /> JKO 1P1�XdW MG0 700 XorooVw%oo I000ao qO>:OOJJO%.V ii<VO:«O:C \!J�W.<..w A:9�:!<O:Ci>iiii:' ..•v:.•....i'!.:!.i:! is i::!!!Ci:!::.'.:v>i:tiMK!4:O:CtO%nV\Sf.:0:000%tN%JKObW 100w�—N000>-10000P 100 —MOVW-- <br /> a ..�.., avc• �.: r. <br /> 'LOFfE tI "CYOG CCYd S7 CCOE A1•f0UN7 RCVD E~CX"� C S:H:> RCW 6Y idf?-kuylve '��'1•�ly z g <br /> s G <br /> :g........... ......... ..... .. .................... ........ .............. ........... I..:.............. ... ....................... ................ :. ....................................... <br /> Ho�%'M XKM %OW�MO►%0000%OOl00�A00C01000%i00i%0>:L!!OO:NO:d!!J:CIO:cu!yy!!t0:9•A:C^:Miv,!•:!!Lyi iw{.i:Ci:i!••%•:Cii i' :!!Sf!!.�!O�!C<O:N.O:000LO!000100V40%00 J000)OWO�)oa0 A00a>AO�MOOW MO�%aM Ao�M.�MOW�)000 J00� <br /> )Tett A2Y9P7H6 >Dtfi >bY6�tAi 7lSoLil2DY foLJLySi'x>)LxY:JYf:.`Y:: -..`�JS:i`).:5;;'.Y' i;Y:'Lii 2:?.`.S:v'+^.:).^•.:":v:'.'•::�::•`.::Y `;�ii';:Y .,.......::Yir: :.`.>i 2siw.,Xi>'.Y>7`.2Y.'Y.Rl r7AY �%RDDDY AiAi%t01Y>mAi AfeLDy Sd%�R7i ALD'e�l>DDY>D'mi <br /> Cut 7Z -ri�9 /DFV 17/J/./Onl f—'^�^� POOR 11 <br />