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Y .AN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 40 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F q <br /> I FACILITY ADDRESS SITE PHONE th AREA CODE <br /> 3 S, Shoe {40vls_�l <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y dyo at SITE <br /> A APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> 1 MAILING AODRES O , APPLICANT PHONE # WITH-AREA CODE <br /> C <br /> A <br /> N CITY _ STATE ZIP CODE TYPE of APPLICATION rue 9 Yc� - <br /> T ` CLOSURE, INSTALLATION, etc. V <br /> TOTAL <br /> A <br /> C 1986 1987 1 1988 1 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991). = $100.00 _ <br /> 1 /Ot) 1607 100 100 op) S D <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) 8170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 198f 198e 1989 1990 1991 1 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) S© Q �5D c5© $ <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> I <br /> T # Tanks x 856.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) _ <br /> S S $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours min 5 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for r <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK I S <br /> P PLAN CHECK (Install. Plan Review 8 Construe' ,l <br /> L <br /> A <br /> R 6WI t g g�o $ <br /> E <br /> a" $ <br /> S <br /> M V /'li�k��� V �J / �W/`•�'•- m I//1� <br /> C FEE = S 53.00/hr v <br /> TOTAL DUE S 00 <br /> ( <br /> a�' T1CU177••i2'CV17,..,'."i.CHECK"'�/CA��H '�RLW"'BS°��'�i�'i�C�(�E�""�'�c�`�" "9a s <br /> s <br /> V + ptC,+n + • a r <br /> s......................1........................1........................1........................1.................................. .............................. .8 <br /> %N MttM MA YIM%N.'MW%N AM XPW%M%lWY.T%%W:KP:ttfP>%f FN:<C'M MC YtYY:tt6%04Ft!M:h'P%PiM%!C:C:CW%fP%ttt0>%P YA M(PM tp%gN%M.WO%MAfOM IMTtl MO.WIp MN LYM MIPM MtY�kNMM <br /> df6YD'6AW%A%AX4YAXiRS%�A0.8)�.`f�lA6Y#�Y+Y.YXA1Y abY' .XTaY^`)).S:SSY::C^'AVf�.'.�Y:b`.Si.Y::S:iF:f.CwR`6'..^S:'b'.59AY>A��#�A.��19.OY �fATd6%.i%WfY�fA�9.m1Ati 9.dit0�lAtY <br /> PW 71 n77 iocv 1712Ai0n1 it Daae t1 <br /> t <br /> i <br />