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• N JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> • UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> tA Q`c-l�C k.0 <br /> C <br /> I FACILITY ADDRESS t� /1 SITE PHONE # with AREA CODE <br /> � S Qll c/�7 <br /> T CITY __7_f_STATE YIP CODE # of TANKS <br /> Y � z I 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 /> CD .% <br /> A <br /> N CITY STATE IZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <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 s <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F 0 Tanks = 1986 1987 1 1988 1989 1 1990 1 1991 1 1992 1993 1 1994 1 1995 1 1996 <br /> A (multiply # by fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> 1 <br /> T # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = S <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 <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum 3 <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE = $53.00/hr FEE = S53.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> .............................................................................................................................................................................................................................................................. <br /> xN»»xolw xa@ x W M>M ammo weo)W►MlaoO79a:o0afo 7 W►x!a@ x<e Xaax•x<o:"Aa:wxo:@:@ x«vD:oa:!ti.:@ rta>ra:A'M@:a:@::@xa:ha:•xa:•>xx.•:.!aN::!o:t:@>uwroe.xo:ex¢e xea recce xa xao woome+wo%eoos loos»aM xos leeeM 10os�xoM►IBO►we <br /> »g S iw -Tan- -rde 0!E x, z'�1'IST�Ci�)E s:x> A�10U}i`(aR'C�:.^•.s;��:.tF{ECfC>'a�1'Cii�xN.>..xs�t�1%�1 <br /> s a <br /> .. Puicf< 20 .aa 1 <br /> xa@xtii loaniiN iwiM ieiiealen»e►»oomsua xwwxoo xaoo xoo xi-0t?:OLO'K@xSK@:C.Jx9:M:a;@'!UiM'{i@xK•AS!M:A4700:�]6x!aKCa7:!!@TY1N0>X@:t!ORKtY:t6®%OPOP!iN%Ot917009�M Me00010q 100N>11M is1oM1Nl1NMl10MfM DNMIOMiM '�� <br /> liar 1ARRAF Amm WAR;19 AY�Fs�":�'.Y9.z`;.5�YR':S$.V:Y.Y:R�`'•S;�S:.YR:�Y^.:IA^Tf,SsX^YwY rYAtROg%�NMWNXKfPA�AMi 6�1t90at f <br /> cw 9t n1t7 rory 19/3A/Ctit ft p7oe tt <br />