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�i JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A S�t,C,E�Y7r r ✓4'i15/� SG�i+ ��Q�i'GL <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> I <br /> T CITY STATE ZIP CODE ! of TANKS <br /> YDe Qf YS>K.1! at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P /I <br /> fiV G�fD i'1 Cr1 //`-82211 /'?Ctit[� G�Prt GT P/<'J <br /> 1 MAILING ADDRESS APPLICANT PHONE # WITN'AREA CODE <br /> A P3� .ems L « /6 - � - // <br /> N CITY S ATE ZIP CODE TY APPLICATION <br /> T Ptf SG Ci.c�i,,.rz Ila � q� LOSURE INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I S <br /> V <br /> TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks 1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # -by fee for <br /> C each year applicable) S <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 2 S Code, Section 25287 <br /> T I # Tanks x S56.00 1986 through 1990 1991 through 1996 <br /> 7 (enter —m mt and year) <br /> � S <br /> PERMANENT CLOSURE (Remov or Authorized Clasure-in•Place) TANK I.D. #(s) <br /> C <br /> L CL - 553.00 per hour (3 hours minimum per TANK) # TANK(s) X 5159.00 = 5 la 7l O v <br /> 0 P <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 2 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK # TANK(s) X 2150.00 = S <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 mini mm per Facility) = $424.00 minimum f <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = 853.00 per hour (3 hour minimum per facility = S159.00) S <br /> M CONSULTATIONS _ UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = S 53.00/hr �---1 <br /> TOTAL DUE /O 7d O <br /> OFFICE USE ONLY <br /> ...... <br /> .....��. ..,.. ... ......_ .w...:«.:<«......._»_<,,. :.e.»w. :,o.:eee.,e<e:vee,.we z«.aw :.«e:.................._.. ............................... ............ ... <br /> EE TTS�' COtA OCCCT)F� �'ISY C1'.OE'•rx ,F4dinY-, <br /> VcVb'- CKE'EeWIE.15�i'' ,sRC`4�'8Y's""'�'hTe' <br /> ap%�... ea /a13.. 91......................; <br /> sawr�_,rwaxs�cwasawusz,axxaxxzA:si;:x z: as:a:::zsxx.:x:::�:w>::irs>�'w�.�+�as:.z:.��ssf:� '�:ait awaassx`as a'saw:ryo'w�`uawcwr,.r <br /> cu <br /> 71 n12 iocv 17/7A/Onl i, NEW <br /> Pman 11 .. ,ow <br />