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UNDON JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RCUND STORAGE TANK PROGRAM - FEE WCRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F � <br /> A G G S >/� C/ i� c' y y r � .S 4 �c <br /> C <br /> I FACILITY AOORESS SITE PHONE 4 with AREA CODE <br /> L )3cv 3 /fw 9 2<» z39 / z /s <br /> T LCITY STATE ZIP CODE 1 of TANKS 1 <br /> Y /, ( �1 �� 753�� at SITE lGu� <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P _ <br /> P l.Yu S Cf r C V i h C-7 C <br /> L <br /> I MAILING ADORESS APPLICANT PHONE 4 WITH AREA CCOE <br /> C C /�w' �Gf 2C�cf Z 3 C / <br /> A <br /> N CITY STATE <br /> IZIP CODE of 3 / PPLICATION <br /> CLOSURE AINSTALLATION, etc. <br /> CA 1 <br /> TOTAL <br /> A <br /> C 1986 19 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 3100.00 <br /> I 3 <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) /TANK (after January 1, 1991) <br /> F X Tanks 1 1986 1987 1988 1 19"0 1991 1992 1993 1996 1 1995 1996 <br /> A (multiply by fee for <br /> C each year applicable) 3 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK,(£1C every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T ;* Tanks x 356.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) 3 <br /> PERMANENT CLOSURE emovafi r Authorized CLosure-in-Place) TANK I.D. l(s)1✓/A <br /> C <br /> L CLOSURE FEE = 353.00 per hour (3 hours minimum per TANK) $ TANK(s) 7`w J X 3159.00 <br /> 0 <br /> S <br /> U TEMPCRARY CLOSURE (A one-time permit, for review/inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 3150.00 each TANK x TANK(.) X 5150.00 = 3 <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) XTANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 353.00 per hour (8 hours minimum per Fa )Lity) = $424.00 minimum $ <br /> i <br /> R REPAIR FEE (workplan review & construction inspections) I TANK I.D. l(s) <br /> E <br /> P TANK REPAIR FEE = 353.00 per hour (3 hours mi um/TANK) -- TANK(s) X 5159.00 = 3 <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 our minimum per facility = 5159.00) 3 <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASEE EVALUATION = 353.00/hr $ <br /> I <br /> S <br /> C CCNSULTATICN FEE = S53.00'%hr SAMPLING INSPECTION FEE = 353.00/hr ( $ <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> -,c. wueo xo.c«c.a,c.»mo.�a...vo...,00w xe.»e.o.w,.»....»..:.tee.. "seas aa. <br /> •.0 s^Ys::.•s_. ,Y xs� ,>x: ...,,. rar., � s :�.i cmc"» <br /> —a"c= CCM LOC u3"t I 7I�T SCD"e AMC wr �C'JI3 C tcL/ �1 ASH IEC i'V�J 3� ��Ji A e c Rc�c <br /> � ...............�. ........................y.. ........ ._.- .za ......1.�.... ��° ...........1���- �� ............ ..... .......................... ... % �...................= <br /> �- <br /> EH 23 032 (REV 4!8/91) ft Pace 11 <br />