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-AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET 7 t <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F - <br /> I FACILITY DDRESS SITE PHONE # with AREA CODE <br /> T CITY STATE ZIP CODE # of TANKS , n <br /> Y ( /� ( cJ S l �� at SITE ., <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> s <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA.CODE <br /> A <br /> N ITY STATE ZIP CODE TYPE of APPLICATION <br /> T L- f C�" �'� L��f 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 $ <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 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 = $ <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 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 8 Construction inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours miniax,m per Facility) _ $424.00 minimum $ <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 = $ <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 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 _ $53.00 hrFEE = S 53.00/hr <br /> TOTAL DUE $/ �j O(_J <br /> OFFICE USE ONLY <br /> ........................................................................................:..::....................................................................................... ................................ <br /> ■te.r.1P%v:NV»VaOPP IWe Veaco VAP Vve l4atq l00e:<VY W.O wNto:<tO:W:4T:P)�N:«.wA:o<ati.):P:^:iri.:v:iiY::iYitiiP:is<4::pY`Y:i.Vi:•:�.:�i::i<•i iiJ?:•:VY:S\<?:(<V:o)Po inO\StN.YN MO Fw»AgIPwVSN»NOwPIO»1we»,wP ieiV%wae,wv'1eM <br /> »'�t11" s m�`o►a 'a�` '" oc'fco' ''a" '1YS'T>'t ciiE>,:f»sx>:A1t011In"R.c >'Rcw',Y�Y <br /> WAY� x w g <br /> ...................... ........................ .............:.......... ...........:............ . ....... ....1................. ....)....`�':�.......... ............ ........................................ <br /> ilcP xePlaew>VP AaaPP VaP:aoaP>VPIaoP)oaoaP lo»VoaPP w»tvPo:uo:ara> ce:aa-aP:ra:.o:<o..^:c-is<o:: •x.«:c«a•:<:•::a:<•a:;•»o:<•:«P»:«P::<:• <e:<a<e ��"S w..X>�%ALL'oY fODD1�AfC�AWoY AbY AL7eY AYi xx AW WA No <br /> ANY Air AUW AWxAW M AIODY gDYAtr X"Axr xW SOP 11 saux:: SY:•:S::Jf S;YY:Gff�:":::Y:::S.^••.:`.:::..^.•;;:•'.:::v:;::f i.:::6:: i<`.: �:)Y Y'«.�'" Aar <br /> cu ?z n'i2 iocv 19/7A/anl it 1 <br />