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1 <br /> �\ <br /> ...1 JOACUlN C'JJHTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONMENTAL HEALTH DIVISION r v <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A <br /> C <br /> I FACILITY ADDRESS SITE PHONE i with AREA CODE <br /> L N . irP e-e i�� <br /> Jv5 — YoS 35--vo <br /> T CITY STATE ZIP CODE 7 of TANKS <br /> Y S � ,� /-O r G/u0 y�J1" at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P / <br /> L <br /> I NAILING ADDRESS APPLICANT PHCNE X WITH AREA CODE <br /> C S <br /> A 54 �- <br /> N CITT STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> A h� �... iOTAI <br /> C 1986 1987 1988 1 1989A <br /> -� <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I /00 tS17U o. <br /> V /ov'�c0 U J 2 v <br /> C- <br /> E TANK FEE = 550.00/TANK (prior to J ary 1 1 S170/TANK (after January 1, 1991) \ <br /> F 9 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply X by fee for <br /> C each year applicable) S-U� SU /CO /u /Ou 310 3yp 5 C <br /> I - �(78� —70 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T 9 Tanks / s $56.00 1986 through 1990 1991 through 1996 <br /> Y (nicer amount and year) Q `�Y <br /> PERMANENT CLOSURE (Re=. YaL or Authorized CLosure-in-Place) I TANK I.D. :(s) - p <br /> C G <br /> o CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) X TANK(s) / X 5159.00 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspectiors) TANK I.D. :(s) <br /> R <br /> E TEMPCRARY CLOSURE FEE = $150.00 each TANK : TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. 9(s) <br /> L <br /> AlN PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facility) = S424.00 minimm S <br /> R I REPAIR FE"c (workplan review & construction inspections) TANK I.D. :(s) <br /> "c <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimm/TANK) 9 TANK(s) X 5159.00 = 5 <br /> A <br /> r <br /> R PIPING REPAIR FEE = S53.00 per hour (3 hour minimum per facility = S159.00) S <br /> 1 CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> FEE = S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> _......_......_. ..........._...._............................................ _.._............................_.._._._........_.........................................._.._....._..._.._ <br /> a's:I�fCPiic�ti '—�Lo 'c7sZi'cJ[�— . n�cl-.3"aJii rR'm -�Si�riw <br /> --- __.--- '�'-rum)�.. ......�9.L....... ...._3y.... llS................__.._..... ............................_1............_.� . . ...3 <br /> 23 032 (REV 1/1C/911 ft 11 <br />