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JOACUIN COUNTY PUBLIC HEALTH SERVICES 0 <br /> ENVIRCNMEHTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SIT . NAME I�C K�f�� Pla <br /> �.� FACILITY CON ACT AM€ <br /> Dao <br /> C - <br /> I FACILITY ADDRESS ITE PHO /! i <br /> N t EA CQE <br /> L 3t�� Nc�� rlvoq �� � 1 <br /> I <br /> T CITY S ATE IZ[ CODE N of TANKS <br /> Y f� r 'tf f � —Z0 at SITE ., <br /> A APPLICANT/BILLING NAME �r APPLICANT CONTACT NAME <br /> In lkz <br /> L <br /> I MAIL[ . ADp@ESS i � ? AP LICA?I(lociPHIJNE # u1T�i'ARF,A � <br /> A <br /> N CITY �Lr� A E Z CTYPE of APPLICATION <br /> gODE 52[}r CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A i <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F N Tanks = _� 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply ff by fee for rr}} <br /> C each year applicable) J�'D� 5 JLC 5U IT� 5 �� <br /> 1 <br /> L STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California N 8 S Code, Section 25287 <br /> 1 <br /> TN Tanks�� x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 56 $ 11z � <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) 0 TANK(s) X 5159.00 S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review It inspections TANK I.D. N(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 5150.00 each TANK N TANK(s) X 5150.00 = 5 <br /> P PLAN CHECK (Install; Plan Review & Construction Inspections) TANK I.D. N(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum S <br /> R REPAIR TANK I.D. N(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour 0 hours minimum/TANK) N TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEV & CONSTRUCTION = $53.00 per hour (3 hour minfmm per facility - $159.00) S <br /> M CONSULTATIONS, UNAUTHORIZED RELEASE EVALUATION SAMPLING VECTION <br /> I <br /> S <br /> C FEE = S53.O0/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S LI),5 7 <br /> OFFICE USE ONLY <br /> ................ <br /> ............... <br /> MnO.O.O'.�OY IYOfuYlai lOOO.O:OOO MOO MOMi114O:000M lO21:iRJ4J« N4:l k4J'Yei<QW J.7 it<4itl.F;4.:S3s. WP < \ 35 .J f'rM S ).YAM f«YMN%ftlY<{<tl1Atl>•OOAWY 1MibMMIfO\TF.O.O10��•wiw lMOiM�)ww�J.w wM <br /> �LIEEPS N-r -f�CY::CIE Y xiC;lSH RClrtl•.rgY-c. EdT?51 1'7E <br /> f)-90<U3 O J 321. 5 <br /> f.O X=0 VY OIYI MIDROW <br /> IOM a7z1 O MOOSJ:S Z"raa, ft4:!4xhl.i:%•:«Oftt?tM:<tOk S!�x;iuY:O A.`:4445%?:{!tl:4«Ii Xa Z-aM M%MatlkM lMtl)I...00 AW <br /> !lOO wO MW AWW SOW O.9 IW AN IOD <br /> IYeM 07i WolkY�mpi Itmi 11CPli t9Ai�1cRgi 13O:A1Ct�tpX>x.7S:Yki�Y:Y�,i3 �,Y?;TXS T:.S.^. Y:;{,Y>'.3".C :Y:Y'.;5.':Y:+^Y"?"':Y:t:y;i?':5;:%'."`�-�Y t.RY ixr:�Yf IY�i.S:7.Y A:Y>;:��.0!IiIK R6wT,ipt IYCAgi AOfi sDnli lou 11o�Y P�>bR�+n7i doM <br /> ru 71 nz7 iocv 1.7/m/onl fr <br />