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�AN JOAOUIN COUNTY PUBLIC HEALTH SERVICES • <br /> ` ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> w.d Gcv . eoOv�T G . <br /> I FACILITY ADDRESS SITE PHONE k with AREA CODE <br /> L �f 1 s. e-'DU <br /> 1 <br /> T CITY STATEZIP CODE atof TANKS r <br /> Y f�°�TL�yt o� 61 -771a <br /> A APPLICANT/BILLING NAME APP (CANT CONTACT NAME <br /> P <br /> P <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE p WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUALFACILITYFEE (Prior to January 1, 1991) 8100.00 <br /> V <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) S170/TANK (after January 1, 1991) <br /> F C Tanks1986 1987 1988 1 1989 1 1990 1991 1 1992 1 1993 1994 1 1995 1996 <br /> A (multiply M by fee for <br /> C each year applicable) 150 S <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> ( <br /> T a Tanks x $56.00 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. k(a) <br /> C <br /> L CLOSURE FEE - S53.00 per hour (3 hours minimum per TANK) 0 TANK(s)_ X S159.00 S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d Inspections TANK I.D. N(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK k TANK(s) _ X $150.00 S <br /> PPLAN CHECK (install. Plan Review 6 Construction Inspections) TANK I.D. W(s) <br /> L <br /> F-J <br /> minimum PLAN CHECK FEE - $53.00 per hour (8 hours minimper Facility) = $424.00 mini mm <br /> R REPAIR TANK I.D. N(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) X TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility - S159.00) S <br /> NCONSULTATIONS _ UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C I FEE = 553.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S C Gf� <br /> OFFICE USE ONLY <br /> w <br /> .................................................................................._............................................................. <br /> wwwwwww.w.rw.w<.,+rvssu.x.exee:.,ws:ea:«wswn.rw.:ue:w.:e:awaw:u:ewxn.nareaea•::<:"......i••<::�•••••• • ••••••••••••.w., m,e <br /> +=3` EPS' :0'Lo" "d�°1f oti x" ''1i�s'i ccoE: :" }oliiir'^RC 1">:;s:•:l>C'r�fECR" /c,ISil., Y:f 11c41)>:;9Y;'c� ` Ew'` "WOIT <br /> a Y <br /> r <br /> •••••'w ••••••..•.••••• .... ••••••••••••••••••••••••••maa<.e:aemnro.avF<a:aYxw.e>.m:nexme:«::�«.w.n:i <br /> flfYifms fR SM f=ftfffWf%AN2Y tLt 9AY ff.TfL9S;>Yf>.^.531.:yF: ..Y«..;'iSY.�.C.`:X:Y�:'S.'�::+::'::;:Y:Y:nS?:"S'::.�.:S f).w;:T L.S:R)Y@J� .O NAf1t Y0Y8MWi9tRMi ieAafi Aur iraUM Rafal <br /> =m 21 ni, iocv 12/?A/0nt Fr Pnee It Y <br />