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-..N JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE wORKSNFFT <br />F <br />FACILITY SITE NAME <br />CAL i� >HtcJA (� c L <br />FACILITY CONTACT NAME <br />l r9 Com, C 4, <br />I <br />1 <br />FACILITY ADDRESS <br />3 S - fsRA UTA i WJE /2�� <br />SITE PHONE 0with AREA CODE <br />a�„ - 5_ 9 z ri <br />T <br />Y <br />CITY �> <br />TK C '�79- <br />STATE <br />C%f <br />ZIP CODE <br />9, !S7 37(, <br />M of TANKS <br />at SITE <br />AA <br />P <br />APPLICANT/BILLING NAME <br />% /� - 4Y 1 N % i9�cJ Gc� <br />APP"T CONTACT NAME <br />/' � s /%�ATHG ccs SUn/ <br />R <br />MAILING ADDRESS G c OA /C <br />C/1• <br />APPLICANT NONE �YITH AREA CODE . <br />N <br />T <br />CITY�J <br />---)�. / �T A e <br />STA E <br />C <br />ZIP <br />y <br />_CODE <br />5/SY <br />TYPE of MPLI CA <br />CLOSURE, INSTALLATION, •tc. <br />A <br />TOTAL <br />T <br />I <br />V <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />1986 1987 1988 1989 1990 <br />I <br />S <br />E <br />TANK FEE • S50.00/TANK (prior to January 1,1991) <br />5170/TANK (after January 1, 1991) <br />F <br />A <br />C <br />1 <br />/ Tanks • <br />(multiply IFfee for <br />each year appllicable) <br />1986 1987 1988 1989 1990 <br />1991 1992 1993 19% 1995 19% <br />5 <br />L <br />I <br />STATE SURCHARGE • S56.00 each TANK (Due every 5 years) Sae California H L S Code, Section 25287 <br />T <br />Y <br />a Tanks x$56.00 <br />(enter amount and year) <br />1966 through 1990 <br />1991 through 1996 <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. /(a) <br />LO <br />CLOSURE FEE • S53.00 per hour (3 hours mininlun per TANK) <br />/ TANK(&)_ X $159.00 • <br />S <br />S <br />R <br />TEMPORARY CLOSURE (A one-time permit, for review/inspections) <br />TANK I.D. !(s) <br />E <br />TEMPORARY CLOSURE FEE • $150.00 each TANK <br />k TANK(s) X 5150.00 • <br />f <br />P1 <br />L <br />PLAN CHECK (Install. Plan Review 8 Construction Inspections) <br />TANK I.D. #(a) <br />A <br />N <br />PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) <br />• $424.00 minimum <br />S <br />R <br />E <br />REPAIR FEE (workplan review 8 construction inspections) <br />TANK I.D. #(a)� - 71e 4 <br />P <br />A <br />TANK REPAIR FEE • S53.00 per hour (3 hours minimum/TANK) <br />1 TANK(s) X $159.00 • <br />5 l — <br />1 <br />R <br />PIPING REPAIR FEE • 253.00 per hour (3 hour minimum per facility <br />• $159.00) <br />S <br />M <br />I <br />TRANSFER FEE • 520 . �GI UNAUTHORIZED RELEASE EVALUATION • S53.00/hr <br />5 <br />S <br />ClCONSULTATION <br />FEE • 553.00/hr SAMPLING INSPECTION FEE <br />• $53.00/hr <br />5 <br />TOTAL DUE 15 / S <br />cn co U�4 (xtV 4/0/YI) 1t <br />