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SAN JOAIXIIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A MA kZb2 STS 1 /QHS S►.�� <br /> G <br /> 1 FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> IZ 5 F: - <br /> T CITY STATE ZIP CODE # of TANKS <br /> y S-1 &zVi at SITE <br /> A APPLICANT/BILLING NAME � APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A STATE ZIP CODE TYPE of APPLICATION <br /> N CITY <br /> T CLOSURE, INSTALLATION, etc. <br /> OAK <br /> FACILITY FEE $100.00 each SITE ADDRESS per YEARTOTAL <br /> A <br /> C 1986 1987 1988 1 19 1990 1991 1992 1993 1994 1995 1996 <br /> I [Cie, I 10c, 100 tLP0 <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F # Tanks x $50.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> Ceach year applicable) ISO I ISS 1S(✓ � E 'QST <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 8 SAFETY CODE, Sec 25287 for applicability) <br /> 1 <br /> T # Tanks x $56.00 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> Y (enter amount and year) �j / G <br /> E <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> C <br /> L CLOSURE FEE = $90.00 each TANK # Tanks x $90.00 E 2170 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> R <br /> E TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks x $90.00 E <br /> P PLAN CHECK (I,stallati on or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) $ <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each SUBMISSION/RESUBMI Ss10N # Tanks x $110.00 E <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 1 <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.00/hr FEE = $35.00/hr FEE = $35.00/hr $ <br /> I� <br /> TOTAL DUE E I g <br /> OFFICE.USE ONLY AM CU"* ILL'VC!... ..y.LC�a�!,.L..I N, .,V�_�p-(JL ,O•, V ;C,1. <br /> »ee=e.»e..wewme»»»e».»e.»eewe»e»ee»»ee»ee» s»ee� »w.... ».wwwe.iwe»awe»ee... zoe»...-m . ..............g <br /> �'�" �" e"»'e"wee(weeexe6»ee»eee:eie»eeee»a.».eee»ee»e::�efeeexeoe.,eee.<. <br /> ■ <br /> a <br /> ■ E » <br /> ............... <br /> »ew»w»m»»ee»».»».»»»ew»»»»»»»»oe»»»»»»»»»e.»»»»»»w»»»»ee»»»»»». <br /> mar�rrsaraxa�maax#fn�rswmrrarearasma'arourmmxmxs •r�raxawc�e¢s.�aau�¢ceatt,aavoa�asatt �cmxatt�nwxa�acam esscarsaxa�sm�aox�axaxxw�saxaceax�axce�mxsnanresxis aa«a <br /> FH 23 032 (REV 6/90) it %Wo Paoe 11 �� <br />