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JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> C <br /> IFACILITY ADDRESS SITE PHONE # with AREA CCOE <br /> L 3505 /Jav k)r,�v& 6 e3 Z <br /> I <br /> T CITY � CK STAlE ZIP A # of TANKS J� <br /> Y l/.�d� `J a[ SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITHAREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <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 $ <br /> V <br /> E TANK FEE = $50.00/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) S <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.O. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 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 8 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 (Install. Plan Review b Construction Inspections) F TANK I.D. #(s) 1 <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum S �Z <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = 553.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = 5159.00) S <br /> H CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE = $53.00/hr FEE = $53.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> ................................................................................................ <br /> F zao zeow Hao HCNo Feo zsaoo HW zea zoaoa A00:o0J10 b.V::<.\0:(<0:4/i:4\J�[4:<n:w'J e:P:^::i.:{3' <br /> — <br /> .,Y <br /> zco� �.aw <br /> �a ., H�Ham.a+f Hma. <br /> 'f � xss <br /> »�'s'^S"f7Ecr5'',� COMP CYOCCCD�">"�•U.LSTI;CUE ,11�1CUH7"RC'�TJCFECX"�/C,ISi� ;;.iC`iD dY" I��c ��uc(VE<S <br /> s <br /> 8 L V 12 .5........••,.. .-1. .....1 �j..-!I....................N. .......a <br /> H..H..Ha...H»Hm..Ha.:ma.Ha.Ha.meae.Hu Hama o o xuoa:oa:R ao«.:�• o:.. «.;:«.:<:..:,:..::•>;:, ,.,:,:.;.::< ,;;.,, «<.:«. zuai A$A4 <br /> > I{20 ALD7i#i*29.l3rf0"W)w HAAS MA mus z"�Di lVattY AW I" <br /> cu �i nz7 rocv iP/9F./0f11 fr pnoa 11 <br />