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JOACUIN COUNTY PUBLIC HEALTH SERVICES • <br /> ENVIRONMENTAL HEALTH DIVISICN <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WCRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A J"�UGI <br /> C <br /> io zrel��2r <br /> 1 FACILITY ADDRESS SITE PHONE B with AREA CODE <br /> L ?� " S, c. c25"-fit - >J- 7 <br /> CITY STATE ZIP CODE I $ of TANKS <br /> Y S/-0 61�1 `�5 U/ at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P p <br /> CT/9G %. _ . 6 "�o t -iI& <br /> I NAILING AOnece< _ APPLICANT PHCNE 9 WITH AREA CCOE <br /> G Q, L), ,Jp „r o9- 7j- 73 <br /> A <br /> 4 CITY STATE ZIP CODE T APPLIGTION <br /> T -� �. CLOSL3iE. 1NSTALLATICN, eta. <br /> Cn �i�s TOTAL <br /> A <br /> C 1986 1987 1 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> 1 /UC ov bUo <br /> V <br /> TANK FEE = 550.00/TANX (prior to January 1,1991) 5170/TANK (after, January 1, 1991) <br /> F 'J Tanks = / 1986 1487 19 1989 1990 1991 1992 1945 1994 1995 1996 <br /> A (multiply p oy fee for <br /> C each year applicable) <br /> I o SU flaa lloo4loc,13110t I I I I 5 YO•CD <br /> L STATE SURCHARGE a 556.00 each TANK (Due every 5 years) See California H i S Cade, Section 25297 <br /> I <br /> T 9 Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enteramort aro year) <br /> -co <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. S(a) <br /> C <br /> L CLOSURE FEE $53.00 per hour (3 hours minimus per TAM �I1/`,�tv-a .00 = S <br /> 0 ��(l/ / ) n <br /> U TEMPCRA review/inspect /��e(p.se /ll TI�_„1 <br /> TE'4PCRAAb(t a 00 = 5 <br /> utt;an Irspt; W61 Jr« <br /> A on 14 g;,4,4 PLAN CH minian per. Fm Ivt ve S <br /> GL hG( Ag 5- <br /> R <br /> R REPAIR FEE (workplan review S construction inspections) <br /> -e"'-Ovecl • <br /> P TANK REPAIR FEE = 553.00 per haw (3 hours miniarm/TANX) �GrGtle .00 = S <br /> I <br /> R PIPING REPAIR FEE a 553.00 per hour (3 hour minis per f <br /> XTRANSFER FEE = 520.00 UNAUTHCRIZED RELEASEE S <br /> 1 <br /> S <br /> C CCNSULTATICN FEE = 553.00/hr I SAMPLING INSPECTION FEE • S53.DO/hr S <br /> C - -7 / TOTAL DUE S <br /> OFFICE USE ONLY stb W v <br /> 'm'w•g�•s 's r's,vsari C.)c 'cJ®iMIZ <br /> � awccr a <br /> • �IGSfS Sr�,t J_ s <br /> EH 23 032 (REV 4/8/911 ft Paoe 11 <br />