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JOAQUIN CCUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �. UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE' c��t� Comp�� FACILITY CONTACT NAME <br /> C <br /> FACILITY 00.7 <br /> ADDRESS SITE PHONE # with / c—�� <br /> I !7 O' <br /> T CITY r STATE ZIP E # of TANKS o Z' <br /> Y at SITE `? <br /> A APPLICANT/BILLING MAKE / Cni, �j 1{;� APPLICANT ACT �® <br /> P 0 <br /> ® <br /> I NAILING ADDRESS APPLICANT PHONE # YINAREA CODE <br /> A f ( 2fl3— <br /> N CITY STATE lZIP ccE TYPE of APPLICATION <br /> T tE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) s $100.00 <br /> I S <br /> V <br /> E TANK FEE _ S50.00/7 ',(prior to January 1,1991) S17O/TANK (after January 1, 1491) <br /> F # Tanks ffi 1986 1987 1 1 1 1941 1 1993 1 1 1996 <br /> A (muttipty # fee for <br /> C each year appLI te) S <br /> I <br /> L STATE SURCHARGE m $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) I j <br /> 2 , 5 <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in•Ptace) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE m 553.00 per hour (3 hours minimum per TANK) # TANK(s) X 5159.00 = S <br /> 0 <br /> S . <br /> U ° T Y CLOSURE (A -time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E ' TEMPORARY CLOSURE FEE s $150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Instalt. Plan Review & Construction Inspects ) TANK I.D. #(s) <br /> A H 10 <br /> H PLAN CHECK FEE - S53.00 per hoar (8 hours minimum per Facility) ■ $424.00 mini ® S e00 <br /> R REPAIR FEE Cvorkptan review & comtructfon inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE s 553.00 per h (3 hours minimum(TANK) # TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility : $159.00) 5 <br /> N TRANSFER FEE ; S20.00 UNAUTHORIZED RELEASE EVALUATION : 553.00/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE ■ 553.00/hr SAMPLING INSPECTION FEE s S53.00/hr S <br /> TOTAL DUE S 4/Z/, <br /> OFFICE USE ONLY <br /> cc ` t Lt <br /> m S <br /> ' ►xA►� wewaw.io«aaws mar�maiaaamw �manixw»im»maw. eswosuowa ►m»i«w �ama.aea.x«aiwaa►aw:»xaz:ew�u.samwie�wa«am»i►maiw <br /> f�crac xx me :rsxw�ox�x na est re�aaasx sac r�apesgc � aaatswr�wc xac aarc�apcaaAwac�aot mx Aac zaczes ar�ttac <br /> EH 23 032 (REV 4/8/911 ft Pace 11 <br />