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SAN JOAO)IN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM + fEE UORKSHEET <br /> fACTLItY <br /> SITE NAME FACILITY CONTACT NAME <br /> C <br /> 1 FACILITY ADDRESS SITE PHONE_/ with AREA CCOE <br /> T CITY STATE 2111 CODE 0 of TANKS <br /> Y _ �- •� )`. -t;- : . D : At Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L — <br /> I NAILING ADDRESS APPLICANT PHONE / WITH AREA CODE <br /> C <br /> A <br /> N CRIT STATE 21P CODE TYPE of APPLICATION <br /> I CLOSURE, INSTALLATICH, ate. <br /> TOTAL <br /> A — <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) a $100.00 <br /> I S <br /> V <br /> E tANK FEE • 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> f 0 tanks • 19861987 1988 1989 1990 1991 1992 1991 1996 1995 1996 <br /> A (milt(ply I <br /> C each year appllcab(a) S <br /> i <br /> L STATE SURCHARGE A 556.00 each TANK (Due every S years) $ea Callfornla N S S Code, Section 25287 <br /> 1 <br /> T a Tanks - N 156.00 1966 through 1990 1991 through 1996 <br /> T (enter emotnt and year) <br /> 5 <br /> PERMANENT CLOSURE (Removal or Authorized Ctusure•In•Plaae) TANK {S) <br /> C <br /> L CLOSURE FEE • SS3.00 per hour (3 hours mfnlatsa per �t N�) r / tANK(a)_ X 5159.00 a ! <br /> O <br /> ri S <br /> U TEMPORARY CLOSURE (A one-time permlt, for rev eW E Igspeetlons fANX 1.0. E(a) <br /> A <br /> E TEMPORARY CLOSURE FEE A 5150.00 each T N 1 IT tANK(s) X tiS0.00 a 5 <br /> P PLAN CHECK (Irutall. Plan R lbw E CnetrUCLion j0j!Vlq4J TANK 1.0, 5(a) <br /> L <br /> A / i <br /> N PUN CHECK FEE <br /> 553.00 per hour (8 hourl min per feCI(Ity) A $624.00 la)niazsa ! <br /> R REPAIR TANK 1.6. 1(1) <br /> E <br /> P TANK REPAIR FEE a $53.00 per hour 0 hours minlmen/TANK) E TANK(!) X 5159.00 a S <br /> A -- <br /> I <br /> R PIPING REPAIR REVIEW 1 CONSTRUCTION A 553.00 per hour (3 hour mirRIAAfe Per faellfty A 5159.00) 5 <br /> M CONSULTATIONS IMAUTd0Al2E0 AE LEASE EVALUATION SAMPLING INSPEctiolf <br /> I <br /> S <br /> C FEE • 553.00/hr FEE a 553.00/hr FEE A 153.00/hr <br /> AAC TOTAL DUE <br /> Ica MA, <br /> OFFICE USE 5 ) r ' <br /> OLY 6I9� <br /> - - - --- ----- .... -................ <br /> .. <br /> f'dE Er�S€ 1-ws°f"c"L� °�1i 1)� We i" c acit&/cas "CGb"'B'P Tflo ftTT'CE.r li`gir7--I <br /> �+�•.a�aa�talO nt�ataaaRAaRgiAVJ]Y —S W 9Y ^P Y.1}}SES L:4.�_.Y` T£Tk64t)1.4M dlGY A^I }Cq AV��Y brpYlY wt r Yl is sewmawrr�Mia � <br />