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JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAMEFACILITY CONTACT NAME <br /> D S . /a . r� . /ovf S,rEs <br /> 1 FACILITY ADDRESS SITE PHONE K with AREA CODE <br /> L <br /> I <br /> T CITY STATE ZIP CCDEt of TANKS <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> T Q EE �7 //14A / AiV C F /tiG U55 �A�ffE SCYC�I <br /> I MAILING ADDRESS APPLICANT PHONE 9 WITH AREA CODE <br /> A -7) S K mos - 9Zs - i8 <br /> N CITY STA E ZIP CODE TYPE of APPLICATION <br /> TSAa)nJ 1,NAP./s9 4345 4 1 CLOSURE, INSTALLATION, etc. /j10Qyr`_ <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> 1 $ <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) S170/TANK (after January 1, 1991) <br /> F 9 Tanks 1986 1987 1988 1 1989 1990 1 1991 1992 1993 1994 1995 1996 <br /> A (multiply DTfee for <br /> 1 <br /> C each year applicable) f <br /> L <br /> I STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H i S Code, Section 25287 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter ama,nt and year) <br /> f <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TAJIC I.D. #(s) <br /> C <br /> L CLOSURE FEE • 253.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 • 5 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - $150.00 each TANK / TANK(a) X $150.00 • f <br /> P PLAN CHECK (Install. Plan Review i Construction Inspections) TANK I.D. !(s) <br /> L <br /> AN I PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) • $424.00 minimum S <br /> R REPAIR FEE (workplan review i construction inspections) TANK I.D. t(s) <br /> E <br /> P TANK REPAIR FEE • $53.00 per hour (3 hours minimum/TANK) 0 TANK(s) X $159.00 •wo <br /> A <br /> 1 <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility • 5159.00) f <br /> MTRANSFER FEE • $20.00 UNAUTHORIZED RELEASE EVALUATION 553.00/hr f <br /> S <br /> C CCNSULTATION FEE • $53.00/hr SAMPLING INSPECTION FEE • $53.00/hr S <br /> TOTAL DUE $ 3 113o .Da <br /> -:-._.-.:,. <br /> N�"SGEEDS i' CCiiGii'fE.R'�`>r p"�`O:C.:_e -'t�ti15T'"C6tiE S�Fitkil!'I�RCVD �C�EC d7CA"SH RSC � D' Y"�� Al`E'�k'EGE'IGED <br /> EH 23 032 (REV 4/8/91) ft <br /> 1404 tloZ� °rte <br /> PA'f AH <br /> RECEIVED <br /> JUN 0 5 12.92 <br /> SAN JOAOUIN C&iNTY <br /> PUBLIC HEALTH SE'V!C_S <br /> ENVIRONMENTAL HEALTH GIVi`"OA! <br /> 9 ' <br />