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SAV"JOADUIN COUNTY PUBLIC HEALTH SERVICES lqw <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F <br /> FACILITY SITE NA E , Irt/lFACILITY CONTACT NAME <br /> C 1 n <br /> FACILITY ADDRESS 2 2 7 SITE PHONE # with AREA CODE <br /> T CITY \ STATE ZIP CODE # of TANKS <br /> Y e 1 42 O /) at SITE <br /> A APPLICANT/BILLING NAME APPLICANT TACT NAME <br /> P <br /> P d l� .GN 5 H/� // lC[ <br /> L <br /> I MAILING AD KESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY P TE ZIP CODE TYPE of APPLATION <br /> T � - C y O C_ CLOSURE, INSTAICLLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I f <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 1994 1995T1996 <br /> A (multiply IF y�fee for <br /> C each year applicable) f <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California N 8 S Code, Section 25287 <br /> T # Tanks x 0 1986 through 1990 1991 through 1996 <br /> Y (enter amount andnd yeyear) <br /> f <br /> C TANK I.D. <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) #(s) <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X 5159.00 = $ <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 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> LlA <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Faci Lity) = $424.00 minimum 5 <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = 553.00 per hour (3 hours minimum/TANK) # TANK(s) X 5159.00 = -� <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = $159.00) f <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $53.00/hr 5 <br /> I <br /> S <br /> ClCONSULTATION FEE = 553.00/hr SAMPLING INSPECTION FEE = 553.00/hr E <br /> TOTAL DUE f7S` p U <br /> Q;F.ELGE_V;4N _=._=i.=..=i==ei. �i eiina!iummir!.=.rrei!�miansireai2 _ ..��-.._._ <br /> - siiEEpv tr 1"t8riPulfil C—qac crsn r Mu`ris7°°e u " zFi uu a�vn� et c cis 6°69 r a e D <br /> q . <br /> c U L <br /> igi <br /> .........._......dui! c+..:-!::!i:i !iei::ciiee!!e°3iiii......................................:F:;!:::i:::::::::.....- .::__..T^.!L _I:ie_ <br /> : a::i!i!c:""Siii51i�i1i5!-i!iic!i!i!ii:!!!iii!icuc!i?:!!i!isi.....::ru:::i!i!!1111111!iii3......iii....I.....i....ii!5i'5mJ!' .•'•• <br /> EH 23 032 (REV 4/8/91) ft <br /> .T(M rD z2 <br /> �Na 9 <br />