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JOAOUIN COUNTY PUBLIC HEALTH SERVICSS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> ' FACILITY SITE NAME �/{�— ` `/ FACILITY CONTACT NAME <br /> A / ' / <br /> C <br /> I FACILITY ADDRESS? SITE PHONE 1 with AREA CODE <br /> yya E 5� <br /> T CITY STATE ZIP CODE of TANKS <br /> Y � �(���/� at SITE <br /> A APPLICANT/BILLING/NAME <br /> F/�/ A,� APPLICANT CONTACT NAME <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE d WITH-AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODETYPE of APPLICATION <br /> 7 CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 7986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100.00 <br /> f 5 <br /> V <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 1 Tanks 1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply i!byby fee for <br /> C each year applicable) I I S <br /> 1 <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> I <br /> T Tanks X 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amotnt and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure•in•PLace) TANK I.D. :(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) I 1 TANK(s)_ X 5159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 3 inspections TANK I.D. a(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK . TANK(s) X $150.00 = S <br /> P PLAN CHECK (Ire tall. Plan Review E Cons motion Inspections) TANK I.D. R(s)(/ <br /> Lc <br /> N PLAN CHECK FEE - S53.00 r hour (8 hours minimum per Facility) = $424.00 minimum S /L c7 <br /> R REPAIR TANK I.D. ;(s) 7 <br /> S <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) TANK(s) X 5159.00 = S <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW d CONSTRUCTION = S53.00 per hour (3 hour mini mm per facility = S159.00) S <br /> M CCNSULTATICI7S UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = 553.00/hr fEE = S 53.00/hr <br /> TOTAL DUE 1✓2 <br /> OFFICE USE ONLY <br /> DiST CCCE. .ANCU17T"-Z C.D 'C iE_C ./C..Sn� PFi'b"47 IV-'y �- f6'v�Eii—"r " ! <br /> , <br /> = II <br />