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JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ON <br /> UNDERGROUND STORAGETANKWORKSHEET <br /> F FACILITY SITE NAME FACILITY CONTACT NAME <br /> A -s7-nr n 7- <br /> FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> I <br /> Y CITY STATE ZIP CODE at SITE TANKS <br /> A APPLICANT/BILLING NAME APPLVANT CONTACT NAME <br /> P . <br /> P <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> T CITY STATE Z CODE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, etc. ✓ <br /> A TOTAL <br /> I <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1986 19$7 1988 14$9 1990 <br /> V S <br /> E TANK FEE • 550.00/TANK (Prior ,to January 1,1991) 5170/TANK (after January 1, 1491) <br /> F # Tanks ■ 19861 1987 1988 1984 1440 1491 1992 1443 1994 1995 1996 <br /> A (muttiply #"I'�"fee for <br /> i1443 <br /> year app`icabte) S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California N & S Code, Section 25287 <br /> T # Tanks t � <br /> x $556.00 1986 through 1990 1991 through 1996 <br /> year) <br /> f <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) <br /> C <br /> 0 CLOSURE FEE = $53.00 per hour (3 hours minim per TANK) # TANK(a) X $159.00 = 5 <br /> S <br /> UR TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. Re) <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) <br /> L TANK I.O. #(s) <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) - $424.00 minimum 5 <br /> E REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s)_ <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) # TANK(s) X 5159.00 = S <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hair minimum per facility • $159.00) S <br /> t TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION - 553.00/hr S <br /> S <br /> C CONSULTATION FEE - S53.00/hr SAMPLING INSPECTION FEE = $53.00/hr S <br /> TOTAL DUE 5 � <br /> ---OFf ICE USE ONLY <br /> "NEC=E.G. of <br /> EMM NINE <br /> EH 23 032 (REV 4/8/91) ft <br /> 9 <br />