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JOACUtN COUNTY PUBLIC HEALTH SERVICES • <br /> ENVtRCNMENTAL HEALTH DIVISION <br /> UROE.RGRCUNO STORAGE TANK PROGRAM FEE '.CRKSHEET <br /> ' FACILITY SITE NAME FACILITY CONTACT NAME <br /> A <br /> I FACILITY ADDRESS2 _ SITE PHONE with AREA CODE <br /> q(l <br /> I � ^ <br /> STATE ZIP CODE of TANKS <br /> Y CITY / ' l A Y ` <br /> S K at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> I HAILING ADDRESS APPLICANT PHONE 11 WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> C 11966 1987 11988 11989 11990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 I 1 <br /> I S <br /> V <br /> TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F : Tanks 1986 1987 1988 1 1989 11990 1991 1992 11993 11996 1955 11996 <br /> A (au(ti P(y 7 by fee for <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> T 1 Tanks K 556.00 1986 through 1990 1991 throuSh 1996 <br /> T (enter amou c and year) <br /> S <br /> PE7MANE4T CLOSURE (Removal or Authorized Ctesure-in-Place) I TANK I.D. '(s) I <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) I TANX(s)_ X 5159.00 2 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d inspections TANK 1_0. :(s) <br /> x <br /> = TEMPORARY CLOSURE FEE 2150.00 each TANK I :'TANX(s) _ X 5150.00 = 2 <br /> P PUN CHECK (Install Ptan Review S Construction Inspe^_tions) TANK I.D. =(s) ./ <br /> L1 4 — <br /> A K �S = �-S6 X , �8 <br /> H PIAN CHECK FEE - S53.00 hour (8 hours minim per Facility) - S426.00 minimum <br /> V2-; <br /> �S 7 Z L7 <br /> R REPAIR TANK 1.0. •(s) <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/ ANX) I C TANKS) _ X $159.00 = S <br /> A- <br /> I <br /> x PIPING REPAIR REVIEW d CONSTRUCTION = S53.00 per hour (3 hour minimum per facility - 3159.00) S <br /> N CCRSULTATICNS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C FEE a 553.00/hr __ = 553.00/hr I PEE = S 53.00/hr <br /> TOTAL DUE ` s' 0 z <br /> OFFICE USE ONLY <br /> 1..,__..=so CV-•�YSYrf l4.� > �....- <br /> SOC"CCOc3iv "CC.7E i' ""ATICUN RC:O ",_.,,_C /CASri"�I;zC'ib"iY��J..'c <br />