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*a%rAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1480 <br /> ` UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME 1�� D FACILITY CONTACT NAME <br /> A /-71d S / f <br /> D <br /> 1 FACILITY ADDRESS J q� �, SITE PHONE # with AREA CODE <br /> T CITY r� r</ STATE ZIP CODE # of TANKS <br /> Y J�GI \`-f�f. �+� �- '?51A at SITE <br /> A APPLICANT/BILLING NAME �VvT' L ! )APPLICANT CONTACT NAME <br /> PH1grr S S�ru I7Ut� �7 �� Gcctiir� <br /> 1 MAILING ADDRESS —_j P ONE # WITH AREA CODE <br /> A /55 15 Yl. C-ke S7�AX-4—Aa— <br /> N CITY STATE ZIP CODE TYPE of AP <br /> I F A.,n C �.. /1 ?Q� CLOSURE, NSTALLA7I etc. <br /> FACILITY FEE/= $100.00 each SITE ADDRESS per YEAR �T TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 1991 1992 1993 1 1994 1995 1996 <br /> T <br /> I $ <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F # Tanks x $50.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) 5 0 E O <br /> 1 <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 8 SAFETY CODE, Sec 25287 for applicability) <br /> 1 <br /> T # Tanks x $56.0019 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> Y (enter arrant and year) $5- <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> C <br /> L CLOSURE FEE _ $90.00 each TANK # Tanks z $90.00 E <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $80.00 each TANK # Tanks x $90.00 E <br /> i <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) E 3 O <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each SUBMISSION/RESUBMISSION # Tanks 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 submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr E <br /> TOTAL DUE E <br /> OFFICE USE ONLY uu�� <br /> ................................................................................................................................................................................................................................................................ <br /> . x ww»„»x»xw»,».». »x»a»»»a »x»x »». »�w x <br /> ... ..� <br /> EH 23 032 (REV 61901 ft Pane 11 <br />