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IM JOAQUIN COUNTY PUBLIC HEALTH SERVICES '000 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGALUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS �S- %f SITE PHONE 9 With AREA CODE <br /> L <br /> e_. i - v�o1 Y�S-3SOo <br /> CITY STATE 2IP CODE # of TANKS <br /> T ('� q�U� at SITE <br /> a <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P O v Z <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> 4 CITY STATE ZIP CODE TYP£ of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> C L{ S:_ TOTAL <br /> A <br /> C `lt 19$6 1987 1 1988 1 1989 11990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = S10o.00 _ <br /> [ <br /> V f rC> <br /> TANK FEE 550.00/TANK (prior to Janu ry 1,1991) 5170/TANK (after Janua , 1991) <br /> F 9 Tanks = ,986 1987 J,19 1989' 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) S 67 <br /> L STATE SURCHARGE = $56.00 each T ue every 5 years) See California X i S Code, Section 25297 <br /> I <br /> T # Tanks--,Z- x 256.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 1 S (; <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) TANK I.D. #(S) <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) # TANK(s)_ X 5159.00 = S <br /> 0 <br /> S <br /> U TEMPCRARY CLOSURE (A oro-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> TEMPCRARY CLOSURE FEE 2150.00 each TANK # TANK(s) X $150.00 = s <br /> P PLAN CHECK (Install. Ptan Review 3 Construction Inspections) TANK I.D. #(S) <br /> L <br /> A <br /> 4 PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = 5424.00 mini mm S <br /> R REPAIR FEE (workplan review S construction inspections) I TANK I.D. #(s) <br /> P TANK REPAIR FEE - 253.00 per hour (3 hours minimum/TANK) it TANK(s) _ X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = 553.00 per hour (3 hour minimum per facility - 2159.00) S <br /> H TRANSFER FEE = 520.00 UNAUTHCRIZFD RELEASE EVALUATION - 553.00/hr I I s <br /> S <br /> CC14SULTATION FEE = 553.00/hr SAMPLING INSPECTION FEE - 553.00/hr S <br /> TOTAL DUE S / y,2 <br /> OFFICE USE ONLY <br /> 1 1 i <br /> S s <br /> �..��P�?_ +irO1+�.�'Z- --•� —cccc=�....:c;cccc.. --.—___—.-- --c•--�;=cc-----,= <br /> sa.rsas'aa�iaissssssr'ras's�; s'sssaasrs�arassrrss �siis,�rrsrasrss=o'r s`r <br /> E4 23 032 (REV 4/8/911 it Paw 11 M 2- <br /> 7 <br />