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USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE UORKSHFET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> C / <br /> FA ILI ADDRESS J SITE PHONE # with AREA CODE <br /> I <br /> �. ds <br /> TCITY l^ / STATE ZIP CODE # of TANKS <br /> J yC-D�• _ / U [" at SITE <br /> Y / l.� T(JY'' <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P erA <br /> Sia C <br /> 1 MAIL ADDRESS ^ APPLICANT PHONE # WITH AREA CODE <br /> A / ( 4O/ ATE ZIP CODE TYPE of APPLICATION <br /> 7 CITY ��� -- / CLOSURE, INSTALLATION, etc. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 19II6 1987 7980 198.9 1990 1991 1992 1993 1994 1995 1996 <br /> 1 <br /> � E <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F # Tanks x $50.00 1986 1987 7988 1989 1990 1997 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 8 SAFETY CODE, Sec 25287 for applicability) <br /> 1 <br /> T # Tanks x $56.00 1986 1987 1988 1989 1990 1991 1992 1993 1 1 <br /> amount 994 1995 1996 <br /> Y (enter unt and year) <br /> x <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> C <br /> L CLOSURE FEE = $90.00 each TANK # Tanks x $90.00 E <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> R <br /> E TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks x $90.00 E <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) E <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each SUBMISSION/RESUBMISSION # Tanks x $110.00 -330 — <br /> E — <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan suunitta t) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE = $35.00/hr $ <br /> TOTAL DUE E <br /> OFFICE USE ONLY <br /> ww ww wawa xae www wa waow wa ww wawa.was waea.ww waaae awe wwa.»a.waa aoaew woo www�.wawo woo woo ww.woo wove waa w,ow ww wwm ww was wawa ww www ww wwoo woo awa�.,.ww wawa wm www ww weoa.ww w»woaw was was <br /> ...................... ........................ ...... .............. ,=.= ..: .... .................................. a 31.,x....... .._` -.. ... a .P... . i............. „ . <br /> weweww wax. vwmwwao wawa.ww www woo woo waow wa.wweew»www ww www wawa waaaa: www wwae wo was ieei <br /> FH 23 037 (REV 6/90) ft wy Pane 11 wI <br />