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JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRON14EHFAL HEALTH OIVISION <br /> UNDE40,04'aUN0 STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A c `F / /t.✓��L�. <br /> C <br /> I FACILITY ADDRESS SITE PHONE if with AREA CODE <br /> L <br /> 1STATE ZIP CODE 11 of TANKS <br /> Y <br /> T CITY at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> PL <br /> P !� v <br /> L NAI NG ADDRESS C/ APPLICANT PH 0 WITH AREA CODE <br /> A STATE ZIP CODE TYPE of APPLICATION Q/SIF F'1 ri rvii <br /> T CITY ' � i/ <br /> CLOSURE, INSTALLATION, etc. Al <br /> tj <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I $ <br /> V <br /> E TANK FEE = 550.001TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F C Tanks 1986 1987 1 1988 1 1989 1 1990 1991 1 1992 1 1993 1996 1 1995 1 1996 <br /> A (multiply I by fee for _ <br /> C each year applicable) 100- 1�11 bb— ,3y03zi6 $ a <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> T tl Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> T (enter amount and year) <br /> PERMANENT CLOSURE (Removal ar Authorized Closure-in-Place) TANK I.O. M(s) <br /> CI <br /> L CLOTURE FEE _ 153.00 per hour (3 hours minlnun per TANK) p TANK(s)_ % $159.00 = f 'e-CA 41AC40" <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d Inspections TANK I.D. M(a) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK M TANK(s) % $150.00 = f <br /> P PIAN CHECK (Install. Plan Review d Construction Inspections) TANK I.D. W(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 minimum $ <br /> R REPAIR TANK I.D. p(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) B TANK(s) X 5159.00 = f <br /> A <br /> I <br /> R PIPING REPAIR REVIEW d CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) f <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> [ I FEE _ $53.00/hr FEE - 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> __.._........_».__..».._.._»...._....................................._......._............_....��:.xuiis::«;z-s:•,•e3.:"nuio::im"�aeia:&::x:u::i::v::::.�s`,:y.:::;�.�`.��.��::���:„��:: <br /> -C'0��'d"aV, T�CGbE��"�A�•ICUI)T"��C4D::"':�'.CnECT4"1g/C.15�1�"RC�iT)rvBY 'I�i E�Ccj(TIE$ T�ai'�IY'i <br /> • + <br /> iw rerwl/nae rrwi rawrr ara:F¢JflTin'^xs¢ssn:.:r^.sJ�„r:Y;:��.asasns:ns:)'.^.';::x?:.:.b:S�.^:xxezncx rs�^.s� -r:o,r yr s aYs�arsaaes,ara�s rain <br /> ev 11 nn roev 1217A/gill Fr ` Paoe t1 •moi <br />