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+ JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> - UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> C <br /> [ FACILITY ADDRESS ITE PHONE 0 with AREA CODE <br /> 1 <br /> T CITY STA E ZIP CC(1E 9 of TANKS <br /> �� at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE WITHAREA CODE <br /> C <br /> A <br /> N CITY STATE Zip CCOC iTPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1966 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> 5 <br /> 1 <br /> u <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 9 Tanks = 1986 1987 1988 1984 1990 W"1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) L: $ "T <br /> I <br /> L STATESURCHARGE = S56.00 each TANK (Due every 5 years) See California H B S Code, Section 25287 <br /> I <br /> T 0 Tanks _ x $56.00 1986 through 1990 1991 through 199b <br /> Y (enter amount and year) 5 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. !1(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) tf TANK(s) X 5159.00 = S <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 = $150.00 each TANK N TANK(s) X 5150.00 = "$ <br /> P PLAN CHECK (Install. Plan Review & Construction Irsspections} iANK I.D. tf(s) <br /> L <br /> A 'r <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours mtnirtx,m per Facility) - S424.00 minim an s <br /> R REPAIR TANK I.D. f1(s) <br /> E <br /> P TANK REPAIR, FEE = $53.00 per hour (3 hours minimum/TANK) Al TANK(s) x $159.00 = s <br /> A <br /> 1 - 5159.00) S <br /> R PIPING REPAIR REVIEWb CONSTRUCTION = $53.04 per hour (3 hour minimum per facility <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I . <br /> S <br /> C FEE = S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE Sq�, <br /> OFFICE USE ONLY <br /> ......................................................................... <br /> ..,.,.,...............................,........,....,,......................,....................... <br /> ]M!1•M ams 1M LIMA iFl�Yw i•1Al1.1!!liMIM MV ifR •fi "N!',.'iS.?q {GL:l:O.O(.:i:lO i ':J A{fb} .;1 4{ L 4 6\,>hY,M t'.•.Yt•ACl:ifIM:01i M!lMCO!!'Ml1MMlilY�•�!!MlM r•1M MI!•iIC►w <br /> »x PSS 'a Cqt ' Oi"CD7 :,, ixST.YC: ;w.... f•10liaT'RC4�3..,�... {itECt..,�iLA N...x,.2L4U rg , ;L`�{T X12 C `f/E WAY <br /> t <br /> S As <br /> .....:................ ........................ ....................... ........................ .................................. ......... ...... « <br /> aw aw elr�rlw,qr a.w•1!I•tw riw w»we•sr<oal:<.•vea•r:{c.:u•:es..�•:a:a«s,xe:a{e•swx::rr xctar:sio:<.i•:a:{ea:+.cleo-:rex:+.-.er:t•,:^:•:<a<•::l:erc��xaw�n..ie....sw:n:::�—•—��• ;.:�....w..r <br /> flMffWtAN�A1Y:67Wi��%AT R4T�iL7lLY%bY',I�YSI'3tY.7H A4Y�:)Y:�:Yi:7s:'.2`.5?:�:.::Y:�...,.....`":Y'....,�:x»..............,.............,.::i....�lY:G:y:;"` r`.::.C:•• �1t�M1f JPA$i/ali/Y�f iM�4'ALY pIDC:bK .•"":e• <br /> ru 9i nzo rocV t7r7Arofit rr Pian `1 J�fjt� <br />