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1 1 <br /> *AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSNEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F 911IVC_/V 1&deke-t <br /> A D wat_ ,�.ti ✓ �c <br /> c <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 3 S Ste,° c� <br /> T CITY u� STATE ZIP CODE # of TANKS <br /> Y ! l L"2/�[_ b�°4 at SITE ;1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P C <br /> L <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE # WITH'AREA CODE <br /> '�3 <br /> A <br /> N CITY yy STATE ZIP CODE �CLOSURINSTALLATION, <br /> T � c��s {� ' Cry77� etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I7 <br /> V /�_ lUp� (� �C1d' i UU " 5 l f C) r <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1 991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year appt icabte) d <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Cade, Section 25287 <br /> ----------------------- <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) ,g <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. #(s) <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) _ x $159.00 = <br /> 0 : 7-7 <br /> 5 <br /> U <br /> R TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X 5150.00 = $ <br /> P PLAN CHECK (Install. Ptan Review & Construction Inspections} TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum $ <br /> FREPAIR ETANKD. #(s) <br /> PAIR FEE = $53.00 per hour (3 hours minimum/TANK) S) X $159.00 <br /> REPAIR REVIEW 8 CONSTRUCTION = $53.OD per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZEDRELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE =:$53.00.00 <br /> $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE <br /> U <br /> 1 <br /> OFFICE USE ONLY IS Iry . e L>L � ✓J <br /> »ae w r.oro»oo waoa«xo.bowe.eoo woo,waoe imoa -.....••,••••... Y <br /> F4}V»)O.eh\P:460'%:y:G%V iA It "'��• <br /> J:O vi{{J 'iv:i4�: .-{r.i;t <br /> ,`+.: ::"wl" .•?.} zos xw ioowe i <br /> •Eoco sooaioaa iacaea ' <br /> ....__...... <br /> �� cci�� �i15T:�.� ,.}.::. Af•IOl1txT`RCV13:..;...'. � �ICAS:�>:.�,,ncv(i�:Y��.:,:.>�d� ��`[�`I:�`'�"��t�i�' `'�'.� 4�1I`I' <br /> . . .1. - <br /> g.. .... . <br /> »w Rli iooy»5Y%aw�rw]osweAPiiK1»KN bN IWOW%(O 6'100 CSO KCC4>. 0:94}i M- •. •••••.•••• .... .. ......I.....�..�.1.... » <br /> >vdfA1K �. 1�AtA%7�ipP5p7RfACADY 3b'i fOS`.LY SiSY>SL7.Y AlY...':6: S: .s•vs�-< '{,b a... ..re>:'r aso.as xcoai•xae xoo waw+o»or wo.w na.n:iw iwi xmw:.w s.w»nas».o wa• <br /> cu T4 nz] rorty 1a/7fs/qn1 fe Paoa,ll <br />