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` %�( JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1.01 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> C <br /> 1 FACILITY ADDRESSSire 0� <br /> I #y+i[J��ECCOE7� <br /> z 5• E J 31� <br /> T CITY s� STATE 21P CODE # of TANKS <br /> Y /,149 t0T R.6 1 at SITE � C-(\, \C-. <br /> A APPLICANT/BILLINGAMN E APPLICANT CONTACT NAME <br /> P <br /> L <br /> 1 HAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> C <br /> ASTATE 21P CODE TYPE of APPLICATION <br /> T <br /> N CITY 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 1988 1989 1990 1991 1 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for r <br /> C each year applicable) )fp �p 7� 5V7 9D (70 $ <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> I <br /> T # Tanks_ x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S6 S6 $ ! <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 1159.00 = f C47 <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 = S150.00 each TANK # TANK(s) _ X 5150.00 = $ <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 mini" per Facility) = S424.00 minimum $ <br /> R REPAIR =TANK #(s) <br /> E n <br /> PTANK REPAIR FEE _ $53.00 per hour (3 hours minimum/TANK) # TANK(s) X 5159.00 <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility - S159.00) f <br /> M CONSULTATIONS _ UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION F PUBLIC HUNT?COUNT? <br /> 1 <br /> NV640NMEN H S RVIC <br /> 5 IVIS! .. <br /> C FEE = $53.00/hr FEE $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S 6cr <br /> OFFICE USE ONLY <br /> m'� S°�M't°'C°Ouf �"'�CL�' ��'r"UI ST'CYAE:�� AT10llpT"�RCW"�'~ytnE'CK:OX%�ASiI��•:.CGD�6y"���i{ R��(�E'S"�"Y'���f�`I',�"w� <br /> i r <br /> ......,.:®e:.mea'�ww��wx»x,waasbi�szxmx+ c.-%x:zs�M,.s:�x��s�::.�Ytza.•wH�:w�x:�:�:.�xzss.• m;w/1...aa.......:.,:..::..w�.:... <br /> ow 21 nil 109V 1712AJOA1 Fr Pane �1 �/�— TAN F"jy,(✓ <br />