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JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F rr ,QQ <br /> A C3f3v, N�`fGirvd <br /> C - <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 0-212-- <br /> I <br /> T CITY 4E ZIP CODE # of TANKS <br /> Y � f at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P SANn vrf�f �o . <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> T CITY � � � ATE �P CODE O TYPE of APPLICATION <br /> j� CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1969 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I !ao (OU $ 4d <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks i 1986 1987 1988 1989 1990 1991 1992 19931994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) G] �j U 117 S <br /> C — <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = 5 <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 = S <br /> P PLAN CHECK (Install. Pian Review & Construction Inspections) TANK T.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimun per Facility) = S424.00 minim m TS <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = S159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE = $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> iseswaswooao xoe xowa woo»aw xes�ea»xee»es»aeeaxoa poswwos zaeae7wo pe�peee>xmmow oeos beoae xeaxeo-�woee�ae>beooa»o�waeeo-xeo-xeee.we.au xeaee xes xnnaa xae»aeas xes zesx wea xa.waves was xesa.ms�mmx »eP xe=o.weo- <br /> `i-ee' r 7rezm B?-- <br /> ........ . .... <br /> EN 23 032 (REV 1/10/91) ft Pace 11 <br />