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N JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> -- ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F 7R�K �sP L�fl� GE rZ <br /> A <br /> c F-f SU T l�G70R �• <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L 2-7 g s , rL 7 D P,-t- o l loses.( S;x <br /> of TANKII <br /> Y CITY STATE ZIP 572 0� at SITE I <br /> A APPLICANT/BILLING RARE APPLICANT CONTACT NAME <br /> P Qe�e.�s u$� �l r7oR Go �� GAG w2 <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> S M�P- f3 t.V D <br /> N CITY A Irr STATE I ZIP CODE TTPE of APPLICATION <br /> T S o l.�t y�I�hDR0 l[; -7-7 CLOSURE, INSTALLATION, etc. <br /> I00 )"3, = qO TOTAL <br /> A <br /> C 1986 1987 1988 1,989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 _. <br /> I �)55 co I IjC $ d O J <br /> V <br /> E TANK FEE = $50.DO/TANK (prior to January 1,1991) 5170/TANK .(after January 1, 1991) <br /> F # Tanks = 1986 1987 1 1988 1 1989 1990 1991 1992 1993 1 1994 1995 1996 <br /> A (multiply # by fee for �l p'1 <br /> C each year applicable) I�� S. <br /> I <br /> LSTATE SURCHARGE • 556.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 j�p _.��'Z(��•. <br /> I <br /> T # Tariks__L_ x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) S n <br /> / Z <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 minion per TANK) # TANK(s)_ X $159.00 f <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A ore-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 PLAN CHECK (Instal L. Plan Review 8 Construction Inspectittu) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) _ $424.00 mini mum $ <br /> R REPAIR FEE (workplan review 4 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours miniaLWTANK) # TANK(s) X $159.00 = S <br /> A <br /> 1 <br /> R PIPING REPAIR FEE 553.00 per hour (3 hour minimum per facility = $159.00) S <br /> M TRANSFER FEE = 220.00 UNAUTHORIZED RELEASE EVALUATION = $53.00/hr S <br /> 1 <br /> S <br /> C CONSULTATION FEE _ $53.00/hr SAMPLING INSPECTION FEE = S53.DO/hr S <br /> TOTAL DUE <br /> SZZ ';, <br /> 1 _ <br /> OFFICE USE ONLY <br /> ■ <br /> f = <br /> =••�•__. wrrr�rawsr�r=ra�s=r=�r�w <br /> ■mn sayAc watrsv mss'o�mums�wsmwsnnr=smmnirmeo:n=wrs=arm='+=arAi■■anraraasasrsfssrrwsa■awsasaos <br /> 2 (REV 4/ 11 ft _ Pace 11 <br />