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AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION \: <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME <br /> -� FACILITY CONTACT NAME <br /> A Vo �i(l ;7f9ZVre FeeTu e2 �Oy STEUEusDti <br /> C <br /> ` FACILITY ADDRESS SITE' PHONE� with AREA CODE <br /> I <br /> T CITY //yy���� ST TE ZIP CODE # of TANKS <br /> Y S�v ' T�N G� gSZO6 at SITE ✓ <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> 1NAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A �I zo y sz 9�s <br /> N CITY �'�I STATE ZIP CODE TYPE of APPLICATION <br /> T /'°Q�J�S'(� C',9- C/;53S' CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> I 5 <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1 1994 1 1995 1 1996 <br /> A (multiply # by fee for <br /> C each year applicable) S <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 - S53.00 per hour (3 hours minimum per TANK) # TANK(s)--3_ X $159.00 <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(s) X $150.00 = S <br /> P I 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 mum per Facility) = $424.00 mini mm S <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE - $53.00 per hour (3 hours minimum/TANK) # TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = S159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE s <br /> OFFICE USE ONLY <br /> P°R$ `501 �1f LUI. Ul�l l.Wt I.VU /IASa I.C� UFIt Yf �A9tsa{ <br /> Skil or i 1 O) a <br /> EN 23 032 (REV 1/10/911 ft Pace 11 <br />