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• w. <br /> SAN JOAOLIIN COUNTY PUBLIC HEALTH SERVICE FF� <br /> ENVIRONMENTAL HEALTH DIVISION �2F'�;y-T�1y. ,rl <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET r, <br /> PE U <br /> /rA <br /> IITY SITE NAME FACILITY CONTACT N Iii qT,),.,I. " <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L 37E45T <br /> T CITY STATE 21P CODE # of TANKS <br /> Y T� � Gf+. pjG��(P at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P t?� Mc.L'OQ-r-•y1G1�. <br /> P L7✓� pfyr;2il�* G �i✓ <br /> L <br /> 1 MAILING ADDRESS DD,RES/S APPLICANT PHONE # WITH AREA CODE <br /> 1 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> CP- e3491-7S CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> .I C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I E <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multip(y p—by fee for <br /> C each year applicable) 5 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> I <br /> IT <br /> # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized ClosurA-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) # TANK(s)_,O_ X 5159.00 = F E f5 �+ <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) _ X $150.00 = 5 <br /> P PLAN CHECK (install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK,FEE - $53.00 per hour (8 hours mini mm per Facility) = $424.00 minimum S <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimam/TANK) # TANK(s) X &159.00 = E <br /> A <br /> 1 <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimm per facility = 5159.00) S <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 553.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 553.00/hr SAMPLING INSPECTION FEE = $53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> i:»im.awra.w xss rs..an aw aeses=es wens sew aa.ss asr va.an oew avw.r.r=e.r am ams ar»a.oseess xs.asseswarw»osaw a«awa a+r+r raver ar ar nes ass aaaw rar <br /> -ffo C ' D`i"s1`�cCfs' 'W`E°'K"I/IAf"ll� '&�°ICIM'WAB NWW <br /> a a <br /> a & <br /> a»a...»�.:�::r»aewa.asrawara«»w.a..a.a..a».» a.r <br /> EN 23 032 (REV 4/8/011 ft <br />