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17r <br /> Alf MENT <br /> RECEIVED <br /> AL 23 1992 <br /> SAN i(jAQ'lj!N C LINTY <br /> pUBLIC HE'kl-T'H SEwlICES <br /> ' DIVISIO!� <br /> SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES EWR0Nj%jEIlTALHEALTr <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE <br /> AC� H <br /> FACILITY CONTACT NAME <br /> FACILITY SLIE NAME <br /> A <br /> A SiiE PHONE # with AREA CODE <br /> C <br /> [ FACILITY ADDRESS # of TANKS —� <br /> L SQA ZIP CODE at SITE <br /> I � <br /> T CITY 7 <br /> [sem-+ APPLICANT CONTACT NAME <br /> A APPLICA4T/BILLING NAME <br /> P <br /> P APPLICANT PHONE # WITH AREA CODE <br /> L <br /> I MAILING ADDRESS <br /> C STATE ZIP CODE TYPE of APPLICATION <br /> A CLOSURE, INSTALLATION, etc. <br /> N CITY <br /> T TOTAL <br /> 1986 1987 1988 1989 1994 <br /> A 1 1991) = $100.00 3 <br /> C anuar <br /> T ANNUAL FACILITY FEE (Prior to J 1, 1991) <br /> I 1991) $170/TANK (after January <br /> V 350.00/TANK (Prior to January 1, 1994 1995 1496 <br /> E� TANK FEE _ <br /> 198 <br /> 9 1994 1991 1992 199 <br /> 1986 1987 1988 <br /> F 4 Tanks = yfee for <br /> A (multiply licee fo <br /> C each year app ears) See California H & s Code, Section 25287 <br /> I = 356.00 each TANK (Due every 5 Y <br /> L STATE SURCHARGE 1991 through 1996 <br /> Ix 356.00 1986 through 1990 3 <br /> T # Tanks ear) <br /> Y (enter amount and y <br /> 7AN1C I.D. #(s) <br /> PERMANENT CLOSURE (Removal or Authorized Closure in-Plaee) x 5159.00 = 3 <br /> C r TANK) # TANK(s) <br /> L CLOSURE FEE = 353.00 Per hour (3 hours minimum per <br /> 0 TAMC I.D. 9(s) <br /> S permit for review/inspections) 3 <br /> U TEMPORARY CLOSURE (A one-time Pe # TANK(s) x 3150.00 = <br /> R = $150.00 each TANK <br /> E TEMPORARY CLOSURE FEE <br /> TANK I.D. #(s) <br /> P PLAN CHECK (Install. Plan Review & Construction lnspections) 3 <br /> A r hour (8 hours minimum per r Facility) = 3424.00 minimum <br /> N PLAN CHECK FEE - $53.00 per <br /> TAMC I.D. #(s) <br /> R REPAIR FEE (workplan review $ construction inspectiorss) # TANK(s) <br /> X <br /> $159.00 = $ <br /> E r hour (3 hours minimum/TANK) <br /> P TANK REPAIR FEE = $53.00 pe 3 <br /> A r facility = $159.00) <br /> 1 <br /> R P[PING REPAIR FEE = 353.00 per hour (3 hour mininxm per $ <br /> UNAUTHORIZED RELEASE EVALUATION = 353.00/hr <br /> M TRANSFER FEE $20.00 --. <br /> I $ <br /> = 353.40fhr <br /> C CONSULTATION FEE = 353.00/hr AMPLING INSPECTION FEE TOTAL DUE $ ' <br /> ::. :. ::::.._.:....:..... <br /> of,FI_G ....V.$ ,_OI T. ,--. .::— -:a-~::--:a- s:- ~=:-a ::= r... <br /> ":'�:'::':!':::.:................. ::••::. .....N <br /> D151`���f]0�� p,MOIIN RCVl7 ,� <br /> _:.,....._._.._..=- •---..._...:- -------------- Page 11 <br /> EH 23 032 (REV 4/8f913 ft <br />