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JOAQUIN 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 /> C I C v_ N S ASC <br /> I FACILITY ADDRESS c n SITE PHONE # with AREA CODE <br /> L X01 S CX 0 5�►6 — USO <br /> I <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y S�OG �( C� cj �p6 at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P 4)C, L$� �wAI`l Jf�U�o►}�h\ L Sw�}I� <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 /> 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 = 550.00/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 # 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 & S Code, Section 25287 <br /> i <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> $ <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 = $ <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 1S77 <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = 853.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = 5159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> 1000 zoo zo00►zo0)o<o<o zooz0000zoo woo wa000 woowawo xv::w\v:«o:<<?:0«J:<w:a•:,.::ro;t:<w:oi:•:<4:;:•:•;r;;'ra>;:«.::.«.::<:.:.rr::<.}>:�:•;::...;:;<�i:•>:<.:<:o>:.«o:tta:o:no'F.ca<tto woo 700o wawa ww zooao zoo wowo ww s00000%os xco xww xro xos <br /> »Y'SEP 'a CsOMIt ' CYOir"CO :v.�zsUIST:CCUE9EC1C>s: IC�Is>,�: TtCVI)aYBY�>s: E� LIEuec"�'E�lF11x'nau>» <br /> s s <br /> ...................... .. . .......... ....... .... ... .... . ... ...... .. .... <br /> weawgwwaJoeawaaaa woo woowoa:000<o woo xw000ww zowa:w9 z<tt9 Y<:'<a:rAx<•::o>K•: <•:.::«axa:•:<r.^ix<o:;.>Y.o:;<..::.<:::«^.:�a:x<•:«e <i<o: '•z0000 ic<s xco wwoa zoo ioeeoe iooe w+aoi woo ieeoei wea ieei w000a ieoo ioo► <br /> :D767WYDt7iA�1i> R}%R1gi:DRL1imK 9RY.YSS.S r�L7.:,3SY::::•.�:5`.i`.S::,S�Y::Y:S: ;.'.`�:::3^.:v v.::•isR:�:`.>.;%�::i:::�:::.:5::.�:�:...... ::Ji• �«.Y':.R1�107G>�LDS:L�f kDLif6 Rf%1bL36 AQ�6 Amia�R22bif:DVI:VJF <br /> cu 21 n17 ocv 1:)/2A/0f11 ft p'lop 11 <br />