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TSN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F y <br /> A / <br /> C SITE PHONE : with AREA CODE <br /> I FACILITY ADDRESS_5gVp <br /> L <br /> I <br /> STATE ZIP CODE of TANKS <br /> at SITE <br /> A APPLICANT/BILLING/NAAMM`Ej� APPLICANT CONTACT NAME <br /> P <br /> P <br /> L APPLICANT PHONE 4 WITH AREA CODE <br /> I MAILING ADDRESS <br /> C <br /> N CITY STAT£ ZIP CODE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, etc. <br /> T <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 S <br /> I <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1 ) <br /> F : Tanks = _ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (au ltiply x by fee for I I S <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 8 5 Code, Section 2528 <br /> I 1991 through 1996 <br /> T : Tanks x 556;111r) 1986 through 1990 <br /> Y (enter !m t and eaS <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <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 TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. :(s) <br /> R . TANK(s) __ X 5150.00 = S <br /> E TEMPORARY CLOSURE FEE = 5150.00 each TANK <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. :(s) <br /> L K SAO a �B <br /> A (( [17 <br /> N PLAN CHECK FEE - $53.00 P4 hour (8 hours mini mm per Facility) = $424.00 mini - S 7 Z <br /> R REPAIR TANK I.D. :(s) <br /> P TANK REPAIR FEE = 553.00 per hour (3 hours minimuN7ANK) TANK(s) X 5159.00 = S <br /> A <br /> IS <br /> 2 PIPING REPAIR REVIEW 8 CONSTRUCTION a 553.00 per hour (3 hour minimum per facility = 5159.00) <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> 5 <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE S D <br /> OFFICE USE ONLY <br /> AMC .x,./....,� .._.w'.'.r ms-r.xf........ 2rt5."B a;..... ..� <br /> CUN� RC+SIf _.�c_R .' C�AS`n'.�. �'i <br /> CYD 3Y <br /> AI'�� c Efv� rERI�I� s <br /> L _ 1g �Q _ 3 S / _2z ....... .... ._............._......_. <br />