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r.- <br /> *AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 10 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A I3Ph <br /> C c. <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L ZN W Vv', <br /> . 4f <br /> Ioc©2- 33 y <br /> - �o <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y L®d; I �aY� at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> A <br /> TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I �O Ul1 ©(► (JL'� D $ <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1 1991 1992 1993 1994 1 1995 1 1996 <br /> A (multiply # by fee for <br /> I each year applicable) 16041° �GO�v ©000 /,00' fev°� $,j04oti <br /> b <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See Cali ornia H & S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 1990 IF I <br /> 1991 through 1996 <br /> Y (enter amount and year) F <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> LCLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 <br /> O = S Y �6 <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 = $ <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(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 FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE = $53.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE $ <br /> OFFICE USE ONLY �fiCS Ri'C-eJuu� �076`'� <br /> ......................................................................................................... <br /> . <br /> ..... ......................................................................................................... <br /> ............................ ... <br /> xaaxoo-x000exoaxoeosxeexoeooxoexoexooaxooxoeasx»xeoeaxoazwooxeaxoaxooeexoaxeeos xesxesxeeesxosxeees xesxeezoeeswoaxaeoa�oasxeeeaxosxaexooesxeexoeeaxo>xeeerxooxeoeexeazeeze000woaxos <br /> g.. fi....... :..... .. ............ . ............ .................................. .5`1: a....... .......... .............. <br /> ............. .................. <br /> EH 23 032 (REV 1/10/91) ft Paae 11 <br />