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,4 JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - -FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A G��o l�1 S e F V I c.8 5TA-n oN <br /> C <br /> G <br /> I FACILITY ADDRESS SITE PHONE # with AREA:CODE <br /> L l(o0� g�uTE't �1.. o�R-PDO z09- -Z69U 616 6-S d <br /> I , <br /> T CITY ! STATE ZIP CODE 4 of TANKS <br /> Y STCwI_T&t4 C�' 9aZ�G at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Roe��7 !�• �� ASSaC-IATes +�1P+tz1 M�ooR� , <br /> L <br /> I MAILING ADDRESS JAPPLICANT PHONE # WITH AREA CODE i <br /> C 1137 oFZ.TH NICGDDW e_L._ 15LVtb• T 6vr7._' Kola O <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION fMM01/AL_ <br /> T AL.UMA [b q46jX54 CLOSURE, INSTALLATION, etc. <br /> i <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> I 8 <br /> V <br /> E TANK FEE _ IS50.00/TANK (prior to January 1,1991) 5170/TANK (after January' 1, 1991) <br /> F # Tanks = ! 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply R 1?y;fee for <br /> C each year app(icable) $ <br /> I <br /> L STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T # Tanks x?$56.00 1986 through 1990 1991 through 1996 1 <br /> Y (enter amount and year) $ <br /> -I <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE _ '553.00 per hour (3 hours minimum per TANK) 4 TANK(s) X 5159.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections). TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A i. <br /> N PLAN CHECK FEE: - 853.00 per hour (8 hours minimum per Facility) = $424.00 minimum $ <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. 1.(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = 5 <br /> A <br /> I � - <br /> R PIPING REPAIR FEE = S53.00 per hour (3 hour minimum per facility = $159.00) 5 <br /> 1 <br /> M TRANSFER FEE it = 820.00 UNAUTHORIZED RELEASE EVALUATION = S53.00/hr S <br /> 1 <br /> S <br /> C CONSULTATION FEE = 853.00/hr SAMPLING INSPECTION FEE = 553.00/hr S <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> ........................................................................................................................................................................................................ .. .... <br /> am amams as am,.asass as a.e amr am am..Hw x....M..amu as am ams.m mmm gem amm am am anus.ae.aeee.asieeis a.ass am am i...e.as ao as a.e�>e>d ams ac.em..am.....�..amm�am�..am� <br /> =S7EPs` Et;M T2»y c"ODE "�Dls�T `CoI3"Ertc ID r E ISA ► " rc c° r bv�5�" OAS cc,'�p9�` <br /> •.••.. �............. ........................ E....�..'aSw a:ri �esi..w.iw.ae....... <br /> aoi. x <br /> >rarsara.wa,.am ef.waramrar�awaas <br /> EH 23 032 (REV 4/8/91) ft 'Pane 11 �r <br />