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$AOAQUIN COUNTY PJOLIC HEALTH SERVICES <br /> f/�" y N fir- UNDERGRCUNONSTORAGE� HN <br /> TAIiKPROGRAM - FEEWCRKSHEEf <br /> FACILITY SITE NAME FA ILITY CONTACT NAME <br /> F <br /> C <br /> I FACILITY ADDRESS �r SITE PHONE p with AREA CODE <br /> 1CIiY STATE ZIP COO @ of TANKS <br /> Y 14-1p.r <br /> 4?4,17- at SITE <br /> �lZ <br /> A APPLICANT/91LLING NAME APPLICANT CONTACT NAME <br /> P <br /> 1 RAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> r /Z CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> 1985 1987 1 1988 1989 1990 <br /> C <br /> TL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I ANNUAg00 <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170/TANK (attar January 1, 1991) <br /> F M Tanks 1985 1947 1968 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply A by fee for <br /> c each year appllcab(e) 01" "14V ],,Go <br /> T <br /> L STATE SURCHARGE - $55.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> i <br /> T 0 Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter t.nt and year) qq Is e_ <br /> PERMANENT CLOSURE (Remavat or Authorized Closure-In•Place) TANK 1.0. 0(s) <br /> C f <br /> L CLOSURE FEE a $53.00 per hour (3 hours minimum per TANK) 0 TANK(s) X $159.00 ■ <br /> 0 ' <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d inspections TANK I.D. p(s) <br /> R <br /> E TEMPORARY CLOSURE FEE $150.00 each TANK x TANK(s) X $150.00 f <br /> P PLAN CHECK (Install, plan Review $ Construction Inspections) TANK I.D. p(s) <br /> L <br /> Aa $424.00 minimam $ <br /> N PUH CHECK FEE - $53.00 per hour (8 hours miniaun per Facility$ <br /> R REPAIR TANK I.D. p(s) <br /> E <br /> P TANK REPAIR FEE ■ $53.0+0 per hour (3 hours minimun/TANK) 0 TANK($) X $159.00 = f <br /> A <br /> A PIPING REPAIR REVIEW i CONSTRUCTION ■ 153.00 per hour (] hour minimum per facility a #159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C FEE x $53.00/hr FEE x $53.00/hr FEE 1 53.00/hr <br /> TOTAL DUE f l Cyv <br /> OFFICE USE ONLY .............................._....._................ <br /> ...... ...................................................... ...... ...-. .... .�....... — <br /> r,..•�n..:.r..—.............�....+wsw..w�.......�.,... <br /> :i�E ' ' c't "a' " 01D`'x a: isc1i-azr1C{IIIY �RG�U:..yr Li(ECi(' 1CA511C,�7 9Y <br /> ;7D.3C'... .!4���Lz .... .zZa s. .� <br /> err r.r :waw wr.rrrw s.r aw:rw M:+w+xs�w w.i:wnu a -coat xa�xwra oto wwc raeu •rMrxelYs :'tn•- a...r aw�....w.AW wo so wM.NV MON AW <br /> AW AW <br /> ■Ili Eli sm rr s!M1�II lfal atlY A01Miaw MW AV Ak=yet X=ASAa;SRiy w=i:AY:,�.7.t tt :7x�.Y.wS:.r.:Y:>.i..:.Y. :=l2k1�..�'=4sd;=A4=9$sZ1,Y►i rwa.rAta»wt,K ArrMi flw+i <br /> cu 21 nt] rccv 12r]Ri0fI% fr PGOA �1 <br /> c <br />