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N JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ✓ <br /> UNDE GRCUND STORAGE TANK PROGRAM - FEE WORKSHEET CEI <br /> FACILITY SITE NAME FACILITYCONTACT NAME <br /> k �RG57-�;n/E %ems ipvf hw &. ��tt,, APR o '+ tsst <br /> C i k <br /> 1 FACILITY AD SS SITE PHONE M with AREA CCLjC+T,-(i A L TJI <br /> ¢00 N EG Z�OPa4Do �lo.v�-No Con <br /> T CITY STATE ZIP CODE tY of TANKS /7 tl/ C/OStc//y /9(.^/) <br /> Y S7�ncL'TOn/ g,SZO2 et SITE /3 Y-O LLC CIV' I/'k6-44 ptlr <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P / <br /> P 8R(FG1EY /1;K1E'Stou1� �caC. V�-1LtJ W tt.►�R <br /> L <br /> I HAILING ADDRESS APPLICANT PHONE N WITH AREA CODE <br /> A A.Jr z1a , q:VC.-Zo <br /> N CITY STATE ZIP CODE TYPE of APPLICATION CIVSU AR& RY <br /> T s t--N lqQ9.4Q CLOSURE, INSTALLATION, etc. geiuv A, L <br /> A TOTAL <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 _ $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F 9 Tanks 1986 1 1987 1 1988 1 1989 1990 1991 1992 '1993 1994 1995 1996 <br /> A (multiply M 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 d S Code, Section 25287 <br /> 1 <br /> T R Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter W;Lnt and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-fn-Place) TANK I.D. N(s) N —/ <br /> C <br /> L CLOSURE FEE _ $53.00 per hour (3 hours mfnfnszn per TANK) f TANK(s) X $159.00 = f 2 OF7 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. R(a) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK M TANK(s) X $150.00 = 5 <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. M(a) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Faci(ity) = $424.00 mini mm 5 <br /> R REPAIR FEE (workplan review b construction inspections) TANK I.D. a(s) <br /> E <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minIaWTANK) p TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour 0 hour minimum per facility = 5159.00) 5 <br /> X CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE _ $53.00/hr FEE = f 53.00/hr <br /> TOTAL DUE �— <br /> OFFICE USE ONLY <br /> r wsw"?Tm f 'L"oN"t "1fl`sfi"L�Rig'" h1Y�k'C�"ft"a�'MIT" 'C�"[G�{f'�m "If1T�RE��R1FIf"' a <br /> s ■ <br /> ...'.i.a...«...a.as<...a..r.wa..aa..w,.�a:w.aa.A.,ar.w a..,.,rs..wau.......w.a.w.w M.,ra<......r,.,n..w.Y xr..a.w.....,w..r......es..x. <br /> EX 23 032 fREV 1/10/91) ft �v Pace 11 <br />