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• *AN JOAOUIN COUNTY PUBLIC HEALTH SERVIO • <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> FACILITY SITE NNA�M/E� FACILITY CONTACT NAME <br /> A <br /> C SITE PHONE # with AREA CODE <br /> I FACILITY ADDRESS <br /> L <br /> Y CITY _ / STATEZlP COD D _ # of TANKS <br /> at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P 1 Gf GC.I <br /> L ' <br /> CMAILING ADDRESS� �� �"+ <br /> A J 4- APPLICANT PHONE # WITH AREA CODE <br /> ATE ZIP CODE TYPE of APPLICATION <br /> N CITY ��/ /fA O CLOSURE, INSTALLATION, etc. <br /> T l�`i 17 <br /> TOTAL <br /> A 1986 1987 1988 Z/00-1/oo-1 <br /> 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 X00— E34O.� <br /> 1 <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks 1986 1 1987 1988 1989 1990 1991 1992 1993 1994 7995 1996 <br /> A (mil ti ply k byby fee for u $ <br /> /_ a <br /> C each year applicable) me /QD /QQ 3o Y� l <br /> L <br /> L STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H 5 S Cade, Section 25287 <br /> 1 7986 through 1990 1991 through 1996 <br /> T # Tanks Z'x $56.00 <br /> Y (enter amount and year) <br /> E"EURE (Removal or Authorized Closure•in-PLac a) TANK I.D. #(s) <br /> $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X $159.00 = f <br /> SURE (A one-time permit, for review 8 inspectionsTANK I.D. #(s) <br /> SURE FEE = 5150.00 each TANK # TANK(s) _ K $150.00 = f <br /> P PLAN CHECK (Install. Ptan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 minimum 5 <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) _ X $159.00 = 5 <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimus per facility = 8159.00) f <br /> M 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 f <br /> OFFICE USE ONLY . ... .. ..... .... .... .... .... . ...... .... <br /> ................................ ........................................... .. Y. ... <br /> .w W RMMN rtV,IIw%wN:M Yw pNOMY%uo YW MPV Aw%iA.�f'O%sYm :•: 'YKKO%W`ttN�l4T P`[s%w wN mai,w4 Mu mNOx»Iw Aew.aN)w, <br /> i E " i°CON1fT a# aC TO ' ST fflj ••y:• 'A DU17FfRCVD CHECK#/CASR.ass 'Ctil)1"Erl� IT°RYE�'P7'�CR"�ErIWtl�) IT "v s <br /> m e <br /> ■ r 7 S s» <br /> » 7 O� .................................... <br /> cu Pi no rocv f7/JA/cnl ft Pna P. 11 <br />