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I USAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES \� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 1 601, E ETT N bwc 209-*&W- 2732 <br /> YCITY/ STATn�E IZIP CODE of(�`zAr at SITENKS <br /> A APPLICANT/BILLING NAME ( 7<J 7APPLICANT CONTACT NAME <br /> P <br /> Pu ever "Rr# <br /> 1 MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> D Fo , 76c)X 2Ul 0.59 109-547- 2&-4Z <br /> NCI A E ZIP CODE TYPE of APPLICATION W-00VArr k- <br /> T n752,D CLOSURE, INSTALLATION, etc.sp%L 6M2! <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I 8 <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 1995 1996 <br /> A (multiply # t fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter —m mt and year) <br /> 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 $159.00 <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 = 5150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Instal(. Plan Review & Construction Inspections) TANK I.D. #(a) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = 5424.00 mini mm S <br /> R REPAIR FEE (workplan review & constructi of inspecti o(s) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimua/TANK) # TANK(s) _ X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE - $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S �59� <br /> OFFICE USE ONLY <br /> .............._......................._....._...................._...................._.........................._.................. ._. ....... <br /> rxazm+z=exmxwxmawrwwwxaz+wmxrrw»osxwwx»xwumw zs zxweszxas»sszxs»oris aMS�' _T•:•..••••....•••zw»zui«wHru:exwiiz»wm«z»»iwzF»+ri::iir6w'iiii:. <br /> ..... i.::. <br /> EH 23 032 (REV 1/10/91) it Paae 11 <br />