Laserfiche WebLink
JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION I%q/ <br /> UNDERGROUND STORAGE TANK PROGRAM . FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> /CK /v "dq(-) O1�''G R <br /> I FACT ITY ADDRESS SITE PHONE # with AREA CODE <br /> L S' l ao, 3 - 95 <br /> I <br /> IP CODE <br /> Y ' 2_3, at <br /> CITY / STATE 2& oSITE <br /> NKs „ <br /> A APPLICANT/BILLING NAME W7 17 APPLICANT CONTACT NAME <br /> P J <br /> L <br /> I NAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> A S LSI ararl S� <br /> ' CITY ��) // �STTATE ZIP CODE TYPE of APPLICATION <br /> T "C1 ? ij yi (- �S.23 CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C1986 1987 1988 1 1989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January t, 1991) = 5100.00 <br /> I 1""t� [ I &V <br /> 00 $ add <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) O 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # y fee for <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> T # Tanks 2, x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) �- <br /> 6FS �6 S°' <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 5159.00 S <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 = $150.00 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 minimum per Facility) 5424.00 minimum S <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) # TANK(s) _ X $159.00 = $ <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = 5159.00) 5 <br /> N CONSULTATIONS _ UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C I FEE = $53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> C20E:,I" '.'110(1111'"RIt b ` CflE CSC"Y/'C,15i1'.'�r= T ('Wr"�*WXITV a <br /> r S a <br /> f...... <br /> .... <br /> _.._.._.. ........................ ................... ................................. ........................ .................... .......... ................ .. .................. <br /> ...�.��.�.�.........:.,..»..,..,...>..:..:..«>�o::v;:���..eri«:z>:e«wwwx.>.m�zww':.-.e.•:<6;.:«eex...>:.e:d..xw.:,...,........e...........:�..,..•...�F�:.:�... <br /> 1�111iY{Ai:YW1llRatirai all alYIDT9�1Y 9laaY'DS DY2:Y."."'^JiltYP:RLS�C= x.Yti.�..:IDYGd�Ym.>:h::%C:'i.?�:rx2C:YatT WY."wiY:G:t:�i J`�.::F:XPf 1Y A0Hi]ei mOYYi YIYlYtf111Y AtiY iNYAYMfi <br /> cw 21 nv races tPAA/9nl fr Paan �1 / <br />