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,AN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME 4;Z�IP �CODE <br /> LITY CONTACT NAME <br /> F / <br /> A El pc)rmch' Sr. i�7.2rCrJS A .r1n? n( f(e <br /> C PHONY# with AREA CODE <br /> I FACILITY ADDRESS <br /> L 1700 e/ 0C)rc( o S0 = v7 - 9-200 <br /> 1 - <br /> T CITY Set SITENKS <br /> Y S1c4�1J CAAPPLICANT/BILLING NAME LICANT CONTACT NAME <br /> v �� N �I c tiq e ( S. RC{/VNU s <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> / D S . / s <br /> N CITY STATE ZIP CODE f APPLICATION <br /> T N O (756CL SURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986✓1987 1988 1 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1�1) = $100.0 <br /> ' / 00 0 00 /00 0 <br /> V <br /> E TANK FEE = 550.00/TANK (pa or to January 1,1 994) 5170/TANK (after January 1, 1991) <br /> F # Tanks = r 1986 1987 j 1988/ 1 1 1991 1992 1993 1994 1995 1996 - -- I <br /> A (multiply # by fee for <br /> C each year applicable) c� 50 I50- q S 2/fid' <br /> I <br /> L STATE SURCHARGE - 556.00 each TANK (Due every 5 years) See alifornla H 6 S Code, Section 25287 <br /> I <br /> T # Tanks " x $56.00 1986 through 1991/ 1991 through 199 <br /> Y (enter amount end year) <br /> 280 a80 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s)4 2,3, Y,.S "j <br /> L CLOSURE FEE - $53.00 per hour (3 hours minimus per TANK) # TANK(s)�_ X $159.00 <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 = 5150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review d Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours mini mm per Facility) = $424.00 minimum S <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) - <br /> E <br /> P TANK REPAIR FEE - $53.00 per hour (3 hours minimm/TANK) OF TANK(s) _ X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = 553.00 per hour (3 hour mini mus per facility = 5159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> CFEE = 553.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY .. ..... <br /> .IZ (( 20 <br /> Y..iaiGY:Yia.•••• .ilii: =aenw..iw,w=..:ia.w.aw...i:�.......rr <br /> Ver' <br /> Or Is <br /> E/ DoRI7 <br /> aass..Z.. ._... . ..__..1......... z�zs-..... =-Z7.3G..... Q�z,3;�"....=,t; .�:rt................... /' Y...�l..............._...; <br /> wrzrrzwerrwzwswasMexaaazsrfwtx#srxwrxsm wreerumxmzswzmrasmewasuaNruwsr:ewsprawxasaaix rwwwss s=rrnras:rwwrtfnararawxwrras <br /> EN 23 032 (REV 1/10/911 ft Paae 1 <br /> lk-Z�� <br />