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*a-9AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ~� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNOERGRCUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE MAKE FACILITY CONTACT NAME <br /> f <br /> C <br /> I FAC LIT <br /> ADDRESS SITE PHONE 9 With'AREA LCOE <br /> 0 V P <br /> T CITY STATE ZIP CODE 9 of TANKS <br /> Y ,r� S-3�� at SITE <br /> A APPLICANT/BILLING NAME L. APPLICANT CONTACT NAME <br /> P <br /> P ,l: Cr- (1 o 7-Ew er� <br /> I MAILING ADDRESS APPLICANT PHONE 9 WITH AREA CODE <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> e,4 93 CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> L 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> I 5 <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) i <br /> F 9 Tanks = �, 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (aultlp(y 9 by fee for <br /> C each year applicable) ✓ t/ <br /> $ o?j0 <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California N d B Cade, Section 25287 <br /> 1 <br /> T 9 Tanks, x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Placa) TANK I.D. 9(s) 3 <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) $ TANK(s)_L X $159.00 = f Sy o1� <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d inspections TANK 1.0. 9(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK 9 TANK(s) X $150.00 = f <br /> P PLAN CHECK (Install. Plan Review 3 Construction Inspections) TANK I.D. 9(s) <br /> L <br /> A <br /> H PLAN CHECK FEE - 553.00 per hour (8 hours mini mm per Facility) = $424.00 mini mm f <br /> R REPAIR TANK 1.0. 9(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) 9 TANK(s) X $159.00 = 5 <br /> A <br /> I <br /> R PIPING REPAIR REVIEW d CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVAlUAT10N SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE _ $53.00/hr FEE = 553.00/hr FEE = S 53.001hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> ST'CCOEµ" ASiduirr kc U•, ChE C( .Y <br /> s 1 OCSi <br /> .. .... ... ......................................... <br /> 1RY[InN AAAsaa[asaa AROataaaas xx>as:zaT T�.:�ffGf:Cl�yiS.:ar::aR�•:«.:�:v�=.:.tw"Z'.'.rz:' CT.::xs i�:..:uc:t::�..s..�,..:::ar ar aasm uvx sus las wimYas ss ws aYis <br /> GY Jt nil rmcw 17/71,/onl F, P.ImP it <br />