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I JOACUIN CCUNTY PUBLIC HEALTH SERVICES �7 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDEAGRGUND STORAGE TANK PROGRAM - FES WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> I <br /> FACILITY ADDRESS SITE PHONE N with AREA CCOE <br /> L 7 <br /> I <br /> TCITYI� F STATc" Z�IPCCOE� O at9SITE xs r <br /> y A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P 3Elm W 2,Crda �` 1J, ry71 L rV <br /> L <br /> I NAILING ADDRESS APPLICANT PHCNE 8 WITH•AREA CODE <br /> A<�T�l-� <br /> HCITY . STATE 2 P CCOE TYPE of APPLICATION Yyl D IV I T0R)N& <br /> T ���� 019 S3 CLOSURE, tNSTALLATICii, etc. SSS 7E/Yrti <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> I S <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 0 Tanks = 11 <br /> 986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (Muttipty # by fee for <br /> C, each year applicable) S <br /> I <br /> L STATE SURC.WG. - .$56.00 each TANK .(Due every 5 years) See California H b S Code, Section 25287 <br /> I <br /> T 0 Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> y tenter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Ctasure-in-PLace) TANK I.O. :(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) : TANK(s) X $159.00 = S <br /> 0 <br /> S <br /> TEMPCRARY CLOSURE (A one-time permit, for review $ inspections TANK t.0. #(s) <br /> R -- j <br /> "t TEMPORARY CLOSURE FEE y 5150.00 each TANK #'TANK(s) X 5150.00 a S <br /> UU <br /> P PLAN CHECK (Instatt. Ptan Review & Construction Inspections) TANK I.D. )t(s) <br /> L <br /> A <br /> H PIAN CHECK FEE - S53.00 per hour (8 hours minimum per Facitity) = $424.00 minimum t <br /> R REPAIR TANK I.D. S(s) <br /> P TANK REPAIR FE=_ = $53.00 per hour (3 hours minimum/TANK) r TANKS) X 5159.00 = ; <br /> A <br /> t <br /> A PIPING REPAIR REVIEW & CONSTRUCTION = S53.00 per hour (3 hour minimum per facility = S159.00) S _f <br /> N CCNSULTATICNS _ UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I ' <br /> S <br /> C FEE a $53.00/hr FEE : S53.00/hr FEE S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> :x`_a:i�s:�">:M:µeaca:aG 4u '_r.::r:««::e�:+ww.z::i:i.i►^i,::��:,.:.:�:.�s����..::i::�: <br /> fli�a`1 f��a�17iSA7i• meati «�".t "T a ."`.:^:7::��' .s ..w,, ..:SS +' ':xi.•-�n+..,.. .w>s`Xx•..a`S ^4 �IYF s�:.:;�1i.1� <br /> MC1jNY�•RC+>> a=l �/C.ISn Ci3) <br /> ica iiic re l� x <br /> '�—.....�._�.».�_��—..�.N WYr..F.F.wF M..XM..•M.'"ww... T"" vtiy�y �•..f•w— ..�. .. ...Y�www� ar � .......^....w�w�ir <br /> ..^v."S'i.v+A` ,.:s i::� �:�3':`iif iiil��tlylaW Y11��Yr1[:Iri 7M41�!]Yitfl� <br />