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SAV'JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNOERGRCUNO STORAGE TANK PROGRAM A FEE UORKSNEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A .F.l MP. q� r N i71" e' nl 617r10 <br /> I FACILItY ADORES! lltE FNONE 1 Wlth AREA CCDE <br /> L IT33 LW7* , S. .20�— 7i v/ <br /> T CITY 11 STATE till Mot Al of TAM <br /> Y f�T rg � Z 0 s-- Rt SITE g <br /> A APPLICANT/911.1.1X0 NAME APPLICANT CONTACT RAME <br /> P <br /> L <br /> I RAILING ADDRESS APPLICANT PHONE Al WITH-MEA CODE <br /> C <br /> A <br /> N CItY STAtE LIP COOS TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, ete. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to Januery 1, 1991) • 5100.00 <br /> I ! <br /> V <br /> E TANK FEE • S50.00/TANK (prior t0 January 1,1991) 110/TANK taft/r JArmery 1, 1991) <br /> F F Tanka • 1 1986 1987 1988 1989 1990 1991 1992 1993 1996 1995 1996 <br /> A (aultiply fee For <br /> C each year app(leeble) ! <br /> I <br /> L StA1E SRRRCNAACE A 956.00 etch TANK (Due every S year!) See CallfornlA N A S Cede) Seetlon 25287 <br /> I <br /> r a tanks x 556.00 1986 through 1990 1491 through 1996 <br /> Y (enter emant and year) <br /> ' � S <br /> PERMANENT CLOSURE (Removal or Authorlted CloturA-in'llltA) TANK S) <br /> C <br /> l CLOSURE FEE a $53.00 per hour (3 hour! min{ per ) / TANK ! _ X 3159.06 a ! <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time perm) tet t eN A t n1 AX t. <br /> I6ND. I(!) <br /> R <br /> E TEMPORARY CLOSURE FEE a 5150.00-16e i4llf ItANK(A) _ X 5150.00 + S <br /> P PUN CHECK (Install. Plan R IAN A Cohi tion of ) fANK 1.0, 1(A) <br /> L <br /> A <br /> N PUN CHECK FEE - 553.00 per hour (8 hour! min per Feel(ity) A 5626.00 mintmW ! <br /> R REPAIR WK I.D. 1(S) <br /> E <br /> P TANK REPAIR FEE a !93.00 per hour (3 hours min IfftWTANK) 1 fANK(!) _ X 5154.06 • S <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW A CONSTRUCTION A 593.00 per hour U hour mImIft! par feelllty a 5199.06) 5 <br /> H CONSULTATIONS UNAUTHORIZED RELEASE EVALUAt1ON SAMPLING tNSPECTIOR <br /> I <br /> 5 <br /> C FEE • 553.00/hr FEE a 553.00/hr FEE A S 53.60/hr <br /> TOTAL DUE t <br /> OFFICE USE ONLY <br /> "-w nn v`w:w.w:.:wvv.'.-.>•w uw.:a:x'ar:-- ::.:u-..:.«n»gym '-`wCCCr•••• ......__— <br /> s -------r cJ ick AS <br /> 2, 30 ..3s <br /> .� w,•aiw..w'»w• .-C+n.:wa.x.wrAirn»nea• +ins aw.wn•n•wwww. Cw.�ar n.�.��.��. <br /> +•>rrrwsair sram�agaasA`r�RaAMZL ,CSf:IF^nCifagL`ASaG•]aatTANaMIGaatFaxARZRMfWtffi5rf mfpr rwws ww•r+r rrwrr �'. <br />