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- JOAOUIN COUNTY PUBLIC HEALTH SERVICES � <br /> `� ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> ATi�G S <br /> C Um <br /> I FACIL TY ADDRESS SITE PHONE # with EA CODE <br /> L Cao gay - 5 <br /> ( AT 21PE a4 of t SITE T CITY f _/J_ _ ` <br /> Y t.(/yJ �CPif/U <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> PYl(NtM/t- <br /> P <br /> 1 MAILING ADDRESS y APPLICANT PHONE # WITH•AREA CODE <br /> C I L. <br /> N CITY STAT Z1 CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUALFACILITYFEE (Prior to January 1, 1991) = S100.00 $ <br /> I /00 loo cb /Oo v�6 <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991)✓ $170/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 ��1 (,�!l ,1 <br /> C each year applicable) 10011p(� lCQ )� DA ..TI 0 I I I f / V <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> I <br /> T # Tanks- , x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) 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)_ % f159.00 $ <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 $150.00 = E <br /> P PLAN CHECK (Install. Ptan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> NA PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) _ $424.00 minimum $ <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(S) X $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour 0 hour minimum per facility = $159.00) f <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE = $53.00/hr I FEE = $ 53.00/hr <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> ....__.............................._.................................................................. . ................................................................................................................................................ <br /> s�r�wr� a�ww roswa.ar m.:wwzwaxr »+.M,°.:.`5x:�'wx:.s„-ey..°,.. :.ssX w. :.w.ww+sa.w.a•x...---aww ww..rirsw.wlrw.wa..w.w,s.w <br /> �i S° "=COM) #"° '�`LdC COEb"$T' C'CD-E AIOTINT ROVO Ci(ECk'.*/C',iSii` s�iC`iD"8Y"�i{' °RC (�E "'x' .211 "J "'=i <br /> a....._.. .._.:........ ..................... <br /> cu 21 ni7 rary t7/7A/Onl 1r Pnae 11 L l A) &_A(j C(l 6,1:(Oil� s.�s. <br />