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A AXIS& F +4N <br /> SAH JOAQUIN COUNTY PL18LIC HEALTH SE E: <br /> ENVIRONMENTAL HEALTH 01VIS1CH ' <br /> .,r OERGRCUND STORAGE TANK PROGRAM - FEE WORKSHEET �V-\ <br /> FACILITY SITE NAME 'J <br /> F FACILITY CONTACT HANE <br /> A \ <br /> �1,)I 1,1LU{.a I �C ISI <br /> I FACILI Y ADDRESS <br /> SITE PHONE # with AREA CODE <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y VAC- G� 53�(w at SITE <br /> A APPLICANT/BILLING HANE <br /> P <br /> APPLICANT CONTACT NAME; <br /> 1( Co <br /> I HAILING ADORES / APPLICANT PHCNE # WITH AREA CODE <br /> 1 CITY 277[_! a STATE ZIP CODE TYPE of APPLICATION r � <br /> 1 ,CF G T --A -13Z7S- CLOSURE, INSTALLATION, etc. ��- <br /> t <br /> JIA TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) $100,00 <br /> Y S <br /> E TANK FEE 550.00/TANK {prior to January 1,19913 $170/TANK <br /> {after January 1, 1941} <br /> F 0 Tanks 1986 1987 1988 1989 n1990 1991 1992 1993 1994 1945 1996 <br /> A (multiply # by fee for <br /> C each year applicable) <br /> L STATE SURCHARGE a $56,00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> I <br /> T # Tanksx $58.00 1986 through 1990 1991 through 1995 <br /> Y (enter amount end`year) <br /> $ rf <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK (.0. #(s) <br /> L CLOSURE FEE n $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 $ <br /> 0 � j <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK TANK(s) X $150.00 z $ <br /> P PLAN CHECK (Insta(l. Pian Review b Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = 5424.00 minimum $ ��/� !� <br /> R REPAIR FEE (workplan review S construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159,00 $ <br /> A <br /> 1 <br /> R PIPING REPAIR FEE _ $53,00 per hour (3 hour minimum per facility = s159.00) $ <br /> H CGISULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C FEE = $53.00/hr FEE = S53.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE S � <br /> OFFICE USE ONLY <br /> ■..�,....�.................»».........,........w....,...:ar...�«.»..w.......�..�. ww .::".:�::�...,..:;:......»:.+� uw..mow w.r....w ..rr�..........air...wrr.............w r <br /> A" <br /> XWSTLr�5'." ■` -C IWi $7 ArOrcmIr r `rC " ' 7-) <br /> ...-...... ........ . <br /> sw NNW ow A"W xW""xw mm <br /> $ • <br /> EH 23 1132 (REV 1/10/91) ft Paoe 11 <br />