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SAM JOACUtN COUNTY PUBLIC HEALTH SERVICES - <br /> ENVIRONMENTAL HEALTH OIVISICN <br /> • UNOERtv.10 STORAGE TANK PROGRAM FEE WORKSHEET ../ <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> C <br /> I FACILITY ADDRESS SITE PHONE x with AREA CODE <br /> L 1 1• <br /> 1 <br /> f CITY STATE ZIP CODE x of TANKS <br /> at <br /> SITE / <br /> T � ,G <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME 1� <br /> TOC NAI NG ADDRESS APPLICANT PH(ti�{E 9 WITH ARE=CODE <br /> H <br /> CITY S(A TE 2IP CCOE TTPE of APPA CATION C3%/�1 n '1.. / �� <br /> T J �� 1 CLOSURE, INS TAILAT ICN, etc. 7 <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) - 5100.00 <br /> I f <br /> V <br /> E TANK FEE - S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F f Tanks = 1986 1987 1988 1989 1990 1991 1 1992 1 1993 1996 1995 1996 <br /> A (multiply f by fee for _ _ 1 '-1 <br /> C each year applicable) f {s <br /> 1 <br /> L STATE SURCHARGE * S56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> 1 <br /> T s Tanks x S56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) . <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Pt ace) TANK 1.0, #(a) <br /> C <br /> L C (� / - TANK) 0 TANK($)_ X 5159.00 = f <br /> 5 <br /> U T rn n � n �nspeccions TANK I.O. M(s) <br /> R M TANK(s) X 9150.00 s f <br /> E 1 <br /> P P <br /> ctions) TANK 1.0. AIM <br /> R P t/1'`-'t /,1Z /-1�� / r Facility) - 5626.00 minimum f <br /> E R /tet J4/iL .�1Z I I TANK I.D. @(s) <br /> P T ' 1 WANK) 9 TANK(s) % 5159.00 = f <br /> A <br /> it (3 hour minimum per facility - S159.00) S <br /> ,H C ��• ASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE - $53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> _�..—_.. .._ t ...._....___..___..._..__..______......__..__...._ <br /> tT Ps' =1'mc"ow�afi'm'��'oC"COx P"IM7refi, 1C 111T RCrO. (-[nE t% /C•iSA 'Tr C•0F'BY•�`� i�Te" Cc(T/`E�y' `a)�(�s'� <br /> __._.___._.....: <br /> ssr�aew eaarsarmaoasxam_,s Auuu::rara�wxz.��s.-.:.^„x�-sr..,�� ,;a::z.^.^.ss•os:rxxrnA�an A:sso aaras...s.�saar.sa�+oas <br /> cw ii nim foev V17A/MI fr Paan 11 <br />