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JOAQUIN COUNTY PUBLIC HEALTH SERVICES . <br /> ENVIRONMENTAL HEALTH DIVISION <br /> r UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT HANE <br /> A /� fv }e�LN S �S Mk� <br /> C <br /> LFACILITY ADDRESS ( I 1i n n SITE N N 9;©MREA <br /> I l'C W oC <br /> T CITYII ,(, STATE ZIP CODE # of TANKS <br /> y S�er— � I 6� .. /� at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P c4e Tf+ S v S VJ4,j Q M; <br /> L <br /> CMAILING ADDRESS J l t3 t` �\ '/r APPLICANT PHCNE # WITH AREA CODE <br /> A o( 1 <br /> T CITY PE of APPLICATION <br /> C r� SI E 2�JCCDEr CLOSURE INSTALLATION, etc.R ew0 U1� <br /> J C �j � \ <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) - $100.00 <br /> I 1 <br /> V <br /> TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1 1989 11990 1991 1992 1993 1994 1995 1996 <br /> A (multiply x byby fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE = 556.00 ea ry 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks x 556.00r#Ltpugh 1990 1991 through 1996 <br /> am <br /> Y (enter ount and year) <br /> S <br /> PERMANENT CLOSURE (Remov tam <br /> L @l+�-PLace) TANK I.D. #(s) <br /> L CLOSURE FEE = 153.00 µ��Qu �r�t per K) # TANK(s)�_ X $159.00 <br /> 0 <br /> S <br /> U 'TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) _ x 5150.00 = S <br /> P PLAN CHECK (Instal L. Plan Review 3 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> 4 PLAN CHECK FEE - $53.00 per hour (8 hours minim per Facility) - 5424.00 minimA S <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> P TANK REPAIR FEE - $53.00 per hour (3 hours miniaLWTANK) # TANK(s) _ K 1159.00 S <br /> A <br /> I <br /> R PIPING REPAIR FEE - $53.00 per hour (3 hour minimuo per facility = $159.00) S <br /> X TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION - 153.00/hr 1 <br /> I <br /> S <br /> C CONSULTATION FEE = 253.00/hr SAMPLING INSPECTION FEE - 253.00/hr S <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> 7 'C0�°C t <br /> : S <br /> wwarsata1ranmaamtxsnw,smsrsaarm�Ptarmrms�wPxmw as auosan,.s=.sa.iarsm�nrswKaoao+easarsa�vnarsas�ima.�msmo.nss�ssrfMMsra+osrr <br /> Pace <br /> EN 23 032 (REV 4/8/911 ft 11 <br />