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46AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> l <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAME <br /> F \\ <br /> AY <br /> C SITE PHONE # with AREA CODE <br /> I FACILITY ADDRESS <br /> L I <br /> I STATE ZIP CODE # of TANKS <br /> Y CITECA <br /> at SITE <br /> APPLICANT CONTACT NAME <br /> A APPLICANT/BILLING NAME <br /> P �q <br /> L APPLICANT PHONE # WITH-AREA CODE <br /> I MAILING ADDRESS <br /> C ! Y <br /> A p A/V J 8 TE ZIP CODE TYPE of APPLICATION <br /> TCITY ENV, ��lC�'Q CIS CLOSURE, INSTALLATION, etc. <br /> r� <br /> TOTAL <br /> A f{)/� 1986 1487 1988 1489 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 x <br /> E <br /> Vrior to January 1,19913 x170/TANK (after January 1, 1991) <br /> E TANK FEE = x50.00/TANK (p <br /> F # Tanks —I^ 1986 1987 1988 1489 1990 1991 1992 1993 1994 1995 1946 <br /> A (multiply # by fee for <br /> C each year applicable) C�' <br /> I ears) See California H 8 S Code, section 25287 <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 y <br /> I 1986 through 1994 1991 through 1946 <br /> T # Tanks x $56.00 x <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> TANK I.D. #(s) <br /> C # TANK(s) X x159.00 = x <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, far review & inspections TANK E.D. (s) <br /> R # TANK(s) X $150.00 = $ <br /> E TEMPORARY CLOSURE FEE = x150.00 each TANK <br /> P PLAN CHECK (Install. Plan Review Construction Inspections) TANK I.D. #(s) <br /> w <br /> L <br /> A - x <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) - 5424.00 minimae <br /> TANK C.D. #(s) <br /> Ta <br /> x <br /> AIR FEE = x53.00 per hour (3 hours minimum/TANK) # TANK(s) X x]59.00 = <br /> x <br /> PIPING REPAER REVIEW 8 CONSTRUCTION = x53.00 per hour (3 hour minimum per facility = x154.00) <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S FEE = 553.00/hr FEE = x 53.00/hr <br /> C FEE = x53.001hr <br /> TOTAL DUE $'S3 <br /> OFFICE USE ONLY >5Batt <br /> .::::..:'.y::••••.. •.•.••+:t..TiY.tiMXV:-0:(iP'r:.V%�W:POP iV4>1WXM%NP]aV0.+! <br /> WAP NP%'P AiPP�RPP%qtr%aV W JOro IwP <br /> jwii.�ax�P�xcooP iooi ieewoiwo iouo w000P icon FVtrV%.v.x ro:«e:aaii..us <br /> D:I.P S <br /> E P 4MOV" <br /> " Loc"c60 `'`:�``"•` `ST- A.iau <br /> c'c�}E l)TR.0 ....; ehEc.;> /eAsr♦: r RcvD 9Y. [ 'S2 tCI iE r I <br /> %Sc<P t P�V W <br /> ..'90P:iE: %aP%VP UeaVO�pOi PVP 9`Etr <br /> pyp�}%�MOP HaP'4 FN%PP <br /> �••%VO xwwrmP]ePooP�Vllrowaw0%PXa�P%C4 KSOeP mVP:M:OP:ew:tiKJ;t!tr:V.O:tittO:aW:<M.!P'Y'•:5:: vi N S v: ry .....•,.•r:..0.r.,.r r.:i Y.vr...;`rY ..:".X i�.Y H:7Xr%.� <br /> {�{ '16Jf RLUY� ]YdKRWD�1-0tlY�%a�f�lG£@k'Y S�59L7%;J7Yfv.'in N:Si3.Y is>).5#1�,Y;`.S:v Y.%`.'�+..:s.. .:..•.: ,... <br /> ru 7Z nZ7 rDry t7f7/IQf11 fr <br /> Pnaa ll <br />