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SAN JOAOUIP r0UHTY PUBLIC HEALTH SERVICES <br /> ENV�, DJENTAL HEALTH DIVISION <br /> UNDERGROUND STOWE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE,NAME FACILITY CONTACT NAME <br /> thc " txxCq �Av 7o;,1>F-tI M �:Lt_ <br /> FACILITY ADDRESS SITE PHONE 1 with AREA CODE <br /> CITY f STA�Atr1E ZIP CODZES 1of TANKS 1 <br /> 1 �Z.aG•�f (J" L� 'l j(o a t SITE L - <br /> APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> 1* J0-A-N ra u_ '�;4Art- <br /> RAILING ADDRESS APPLICANT PHONE AT WITH-AREA CODE <br /> �l/✓b lA� , /J24kvAL.1AzA AE. ( 1 0�� Z16 - ()1 <br /> CITY `/ 1 �( l <br /> 0�1 sr�rE Z1� C�Wii� ELOSURE171NSiALLATOION, etc. <br /> LIQ TOTAL <br /> 1906 1987 1988 1989 1990 <br /> ANUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> f <br /> TANK FEE • 550.00/TANK (prior to January 1,1991) $170/TA)IK (after January 1, 1991) p <br /> imks = _ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 MF <br /> (uAtlply IT by fee for <br /> eKh year applicable) g tl -IV <br /> A Br//ff <br /> SIDE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California N 6 S Code, Section 25267 fjvV Ue(/ �qQItank <br /> N <br /> $56.00 <br /> COU <br /> (mterac,ntandyear) 1986 through 1990 1991 through 1996 Pyjq� <br /> PERMANENT CLOSURE (Removal or Authorized Closure-In-Pt ace) TANK I.D. f((gt <br /> CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) 1 TANK( X $159.00 $ �j�tU PQ <br /> TEMPORARY CLOSURE (A one-time permit, for review d Inspections TANK I.C. 1(s) <br /> TEMPORARY CLOSURE FEE _ $150.00 each TANK 1 TANK(s) X 5150.00 f <br /> PLAN CHECK (Install. Ptan Review L Construction inspections) TANK 1.0. 1(s) <br /> PLAN CHECK FEE - $53.00 per hour (B hours minimum per Facility) _ $424.00 minimum f <br /> REPAIR TANK 1.0. 1(s) <br /> TANK REPAIR FEE _ $53.00 per hour (3 hours minimum/TANK) 1 TAHK(s) X $159.00 f <br /> PIPING REPAIR REVIEW 6 CONSTRUCTION - $53.00 per hour (3 hour minimum per facflity = 5159.00) f <br /> CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> IEE = 553.00/hr FEE _ $53.00/hr FEE = f 53.00/hr <br /> TOTAL DUE f <br /> FFICE USE ONLY <br /> RCN) Cv, <br /> FEC��1r/MASH ' —tC1"' '�[�1I <br /> �/9Y�'� �' 77E8 6�'a1�fly `w= <br /> — ................. _. _�� �.D.... � ) �2 .....L.L.:.i _ ... .�_�.�...... .....................i <br /> •\�Yawli�mtMp1PIN~N1ellbti m.l35Y T.xS�plAAl1T..1 a^+T �t":YmSYi#n^�M`1YXY:YXtl�J C�ri�lY{IaMf all aYRRA1IVM�YeO�Y� <br /> IAll (DLV 17 IIA/Onl F, P.IOq �1 <br />