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JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME n ) FACILITY CONTACT NAME <br /> F °, /7 FVs <br /> A <br /> C <br /> t FACILI Y ADDRESS SITE PHONE a with AREA CODE <br /> L <br /> T CITY G (74 Zi(P� cY/� at <br /> ITENKS c ' <br /> Y AI of <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L d _ <br /> I MAIP ADDRESS�-LT l'l.�t�V.- TGLf. - I'• <!/1t LICANT PHONE '# WITH—AREA CODE <br /> C r — U coq 7g— �-- <br /> N CITY ZIP CODE TYPE of APPLICATION <br /> T J 1)9CLOSURE, INSTALLATION, etc. <br /> 8 acfGiaasy1 TOTAL <br /> A <br /> C 1986 1987 1988 1 1989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> o � aoa 5 <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = ,{� 1986 1987 1988 1989 1990 1991 1992 1993 1 1994 1995 1996 <br /> A (multiply Al by fee for <br /> C each year applicable) Ioo a-ItoAo b0 S .� <br /> I <br /> L STATE SURCHARGE = S56.00 each TANK (Due ever 5 Se Lifornia H ode, Section 25287 <br /> f <br /> T 9 Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 5 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK 1. k(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) N TA(K(,) X 5159.00 = 5 <br /> 0 J <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK p TANK(s) X 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. 6(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 mini mm S <br /> R REPAIR TANK I.D. 4(s) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) X TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) S <br /> M CONSULTATIONS UNAUTNORI2ED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE = 553.00/hr FEE = S53.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> w»»w.wtwew memsx.e u:w..ewe:e.w.exm:wwra:w:«rnr:w-.raw:en:a>:m:xo cco:s<.uaaww«as:gem::ii:<:.'<8::'<"vwz.:v.:aW:v�xe:...:�z»ew..:e�ee:•H::�•.• •..• .....•...•.... <br /> oa e.. .y r:si �Ycs' .r• ..�.....•..'.i.... �..::..:.....:.`.°:.•yF... <br /> `, w"` Yx'^^Ju u"S T3 Alt .P:.:ii➢i J8 <br /> :i'3�k�P Otd"11" '�Ol:"O��E �'1 ST CCOE"�' A�•TO�I)11Y RCGD�� '""CFtE CiC'"x/'CASH '�2C4D 8Y ��t'k�Lc�/E� 'e���2�M"(5ss <br /> 5 <br /> s...................... ........................ ...................... ....................... ..................p...V........ ................ . <br /> ...�.......w...w...........».....«.«..:......:e<:..w.:.,,..x.e:.de..•.e:««e><.exe>��.:.«<.:«e:«:e>.e...M,>ro:«:::n:...R:»:��::.�.��.�............................. .... <br /> waxwxwawwamaesta�atsaxt�zs;avxmxaw;asAnz�xux::vurzs�.:x:msz:,zrmrxz x:>ti`�zrx^x�ownx^:.srss>�.muxxx:al.uss,��x,mllc¢allxat¢aaDotewwaaaasrsaat,mxw <br /> ev 21 n1J eoav i?/JA/Gni ie Ploe 11 <br />