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JOACUIN COUNTY PUBLIC HEALTH SERVICES j <br /> ENVIRONMENTAL HEALTH DIVISION • <br /> UNDE NO STORAGE TANK PROGRAM FEE WCRXSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A 0If; By x <br /> C <br /> IFACILITY ADDRESS SITE PHCNE I wi:h AREA CCCE <br /> L 3505 IJQu 13rl�ve) 90(o - 6832- <br /> I <br /> T CITY <br /> CK SiA E ZIPL X of TANKS L <br /> Y II at SITE / <t <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I HAILING ADDRESS APPLICANT PHONE $ WITH-AREA CCCE <br /> C <br /> A <br /> N CITY STATE JZIP CODE STYPE 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) = S100.00 <br /> I S <br /> V <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) S170/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 25237 <br /> 1 <br /> T X Tanks x 556.00 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.D. :(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimun per TANK) I TANK(s) X 5159.00 = S <br /> 0 <br /> S <br /> U TEMPCRARY CLOSURE (A one-time permit, for review S inspections TANK I.O. 9(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK $ TANK(s) X 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review 3 Construction Inspections) TANK I.D. x(s) <br /> L <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimm per Facility) = $424,00 mininun <br /> R REPAIR TANK I.D. X(s) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours miniffLn/TANK) X TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 3 CONSTRUCTION = $53.00 per hour (3 hour minimim per facility = S159.00) S <br /> H CONSULTATIONS UNAUTHCRIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = 553,00/hr I FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> Iwi•srw..wa�.sarr.�swawt..lq lvMf��::[.t.:tt+:t.i.lX.I:OY:q:J:l:1<wta:1:O:.iwl::2•i:iW:lwM:W:. tOr(2•isS4:0�.✓'/t!�N:ti•Y:24t:Jtiw.v�:Ft�:aw�w.�.w�r sw.r.wt•�.w�•��>•l•+����Y�aww w� <br /> ms , p'cc7�Q= �C�P�J CC`CCDc ""�'�7[SiviG'JEw at•ICUtIT" U''as �>CnE: :' ICiSri �:a C:D�3Y�• c2?!!�s <br /> I.. .. C`. <br /> I : <br /> : s <br /> = `�S ► . r.�-..35.. ...... D I 3 21.. S......y..��t .....1. ► ...�X521 9L...._;.....,�;N <br /> ....:... ..... _............. ..... .... <br /> :!?:xxs::A::w:ttTO:!2•s:.:IX.:?:r.)%?Y.+'T.^Y.t•'!H�>..<ett l:t•� 0�l�sw <br /> WX1WA"*X=0a WMAW* "W�w s.lwa.j'=t!t•:wlt•.:t:�:t:�.wew:alxaw ..r•+.,, rv..,...•..r. .......:.........,w,-,,,.,,.....r . .... - �Z.« AMU AW �{11r,Ri A!li ii.iK <br /> Y <br /> 111�]IiTM iiff7l{1R}C11�i!{a1i�{.'AOtS A.Y Y7.)1T S S :f i%� :SA:T:^.:........Y..,............. ..,,.,,..:,.......:.........s....:.:'a:�l.....Y� "'.:Gi.�C�DLi]IPt•••' <br /> cw 21 n'to iocv 17/7//Onl fe <br />