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�IwM JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F e+ / <br /> A <br /> L <br /> ( FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> I -0 --9, s--AtY7 <br /> T CITY STATE ZIP CCOE # of TANKS <br /> Y /_e /_ � QS h/l at SITE � <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> 1 NAILING ADDRESS APPLICANT PHONE # IJITH-AREA CODE <br /> L 9 i6 — - iib a <br /> A <br /> N CITY / SNTTE ZIP CODE TY APPLICATION <br /> T P ST SG C ra i � �v l/7 �/37o Y/ LOSU INSTALLATION, etc. <br /> TOTAL <br /> A <br /> 198 <br /> C 6 1987 1968 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I I $ <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F 9 Tanks = 1986 1987 1988 1989 1 1990 1 1991 1 1992 1993 1994 1 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) f <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> I <br /> 7 # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> E <br /> PERMANENT CLOSURE (Remov or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> L L - f53.00. per hour (3 hours minimum per TANK) # TANK(s) = X 5159.00 = f is,a 06 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK # TANK(s) X $150.00 = $ <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 mini mm $ <br /> R REPAIR TANK I.O. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = E <br /> A <br /> ( <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) 5 <br /> N CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE _ $53.00/hr FEE = 553.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> ;^s'•axa vx. x» ;ps �ssit <br /> '�`Por�"`�iY�COt° °a�'"�"�`3'C �� "E�`s1- CFbE "bft•Ot11)7 RCGU�.:", tHEC1C""Y/�CfASH' <br /> s <br /> fsl.....................; <br /> aaswrrmxumsaxamsxmmxxaasza><asvxmxarxs»x:att;�,:x 'vx'^.x.,s'axz�:Fnraxss�s�aissz:.„z.x`:a:zsa•'uisixrs;�•x •ttsr,wrzuuaswraxxwomxmaxm,m:musa�ax <br /> cu 21 n" toav 12/7R/OJh it Pnaa 11 <br />