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�kN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> LNG :CUND STORAGE TANK PROGRAM - FEE UORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A <br /> C <br /> I FACILITYAD ESS / SITE PHONE x with AREA CODE <br /> L 3 - , a� �/-a - a <br /> I <br /> T CITY ` l STATE ZIP CCOE X of TANKS / <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> N ` o IW41) <br /> L <br /> I MAILING DRESS APPLICANT HCNE X WITH-AREA C00 <br /> G a c��t 75`1- 3 `fC o <br /> A <br /> T CITY �n Z <br /> P CODE TYPE of APPLICATIONlryA�� rCyLOSURE, INSTALLATION, eta. <br /> l Se' 7 O f /to % ;7,d' �J j TOTAL <br /> A <br /> C 1906 1987 1988 1989 1990 <br /> T ANNUALFACILITYFEE (Prior to January 1, 1991) = $100.00 <br /> 1 /�0� !fi[7 r 0 o v IQ elo3 <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) S170/TANK (after January 1, 1991) <br /> F X Tanks = „� 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply S by fee for <br /> C each year applicable) 1561 .6011601 /60 /00 $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> 1 <br /> T X Tanks x 356.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. 9(s) <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) 9 TANK(s)_ X $159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. Vs) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK k TANK(s) X $150.00 = S <br /> PPLAN CHECK (InstalL. Plan Review 6 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (B hours minimum per Facility) = S424.00 mini mum <br /> S <br /> R REPAIR TANK 1.0. X(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) M TANK(s) _ X $159.00 = 5 <br /> A <br /> I <br /> R PIPING REPAIR REVIEW i CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = sl59.00) S <br /> M CONSULTATIONS UNAUTNCRIZEO RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEEEEE - 553.00/hr FEE = S/ 530000//hr <br /> TOTAL DUE 5 <br /> OFFICE USE ONLY <br /> I'VE E75'rrATL014wt" �fe C00-c "yl sff CEZ E T_�WIJ T'rR C1,UI'tnE.X" RASA A013 By TXTE �E?MlE' r' AMY s <br /> ` i <br /> S S a <br /> •...._..... <br /> .......... ........................ ........................ ........................ ................_................ ....................s.. .................... ..............................�......��...........s <br /> a aq Elias dls0 M asams arses a3�:us�eY oir:aals:it�A.=�:a:—=N���'^"...::^�5:#''i:�zY%a:�'�..^^'s�Ta�s:rro rs�.:s��x oas,Wsisw im�t raw�s cs a±.c iars <br /> cm 21 nil /mcw 17/7A/9n1 fr P.IGP. 11 <br />