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N JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE/N,AAME FACILITY CONTACT NAME <br /> A <br /> C <br /> I FACILITY ADDRESS / ^/�%✓IFi�C SITE PHONE # with AREA CODE <br /> L d/ LIr <br /> 1 <br /> Y CITY ��(/ STATS ZIP CODE 7� atoSITENKS <br /> A APPLICANT/BILLING NAME `/�•TL G/I' APPLICANT CONTACT NAME <br /> P <br /> 5of 17,e, <br /> I MAILING ADDRESS APPLICANT PHONE # WITH'AREA CODE <br /> A — 3 s-7, ) <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T ':'� CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> V /GU /ao /vo /vd /o0 $ SOO <br /> E TANK FEE = 850.00/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 # by 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 Code, Section 25287 <br /> I <br /> T # Tanks x 856.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = 853.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = S <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 $150.00 = 5 <br /> P PLAN CHECK (Instal L. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = 8424.00 minimum 5 <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = 853.00 per hour (3 hours minimum/TANK) At TANK(s) X $159.00 = $ <br /> A <br /> I <br /> r, R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = 5159.00) S <br /> , <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 853.00/hr FEE = 553.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> ....................................................................................................... ...................................................................................................................................................... <br /> WMOU(7T"1X413" i CHECK'"d/C'ASH'"""�`�R'CG 3"81' " '�'71 c c E Ji '�' I� IY�" 1#D° <br /> a <br /> ° S <br /> a <br /> A]YA159AJ��,hWYY AIYR:BA.l ANTf9A5 RJ`KN.Y�YYJ>`k`;Y>Yii x:.:S#.^AYH.Y:tiSM'::f>:::i>F:::;':^L')::�:is'�::::�:;:i::%:::::•:•.)••:S:.� e»xee»xee»w xaaexee mmewm wweew»xewexesxa re»xw xo <br /> .. .. YtiRY:R.Y'iSS::.iNtlhl ACtb"TAl V%RSA:gX AMY�Y9Dl�Y�il�RD`3%6YY 5Y <br /> EH 23 032 (REV 12/26/90) ft Pnoe 11 <br />