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' JOACUIN COUNTY PUBLIC HEALTH SERVICES • <br /> ENVIRONMENTAL HEALTH DIVISION <br /> • UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A - <br /> c <br /> 1 FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> Lac <br /> C <br /> T CITY STATE ZIP CCOE # of TANKS <br /> Y n 1:S 2�� at SITE ! <br /> A APPLICANT/BILL[ NAME l �1 APPLICANT CONTACT NAME <br /> P <br /> I HAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> A <br /> STATE ZIP CODE TYPE of APPLICATION <br /> T .�C � c CLOSURE, iNSTALLRT1oN, etc. ��J <br /> `�t,�-�� TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> I S <br /> V <br /> E TANK FEE = $50.00/TA14K (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F 9 Tanks 1986 1987 1988 1989 1990 1 1991 1992 1993 1994 1 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) S <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I - <br /> T # Tanks x 556.00 1986 through 1990, 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = t <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.GO each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install, Plan Review & Construction Inspections) TANK E.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facility) = $424.00 minima f <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) �_ X $159.00 = $ O(J <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = S53.00 per hour (3 hour minimum per facility = S159.00) S <br /> H CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE = $53.00/hr FEE = $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE 5� ,dam <br /> OFFICE USE ONLY <br /> .......................................................................................................................................................................................................................................................... <br /> 7p yew x�o.r 111►iwti••�raw.r:wrlwrlwae�llar:aW'N YNOirWiO ifW;C.iVA%tO:�.WIXW r1 ?w.W:"YrW:3X:�h,i?':*:w%•):};.,.:{{04 .•r .v u:+ : ara.rRrrrc:.r wrwu:noao»wowrr�naaor nw na+w y.r por»wwww:.rt <br /> �'��EePS'� '�C'•R' t3�'� '�OC""COIa�""�"a�3'IYST"CCI1E`• Y�.AI•IDUlI7 li'C';1I3 Y Y'CFiEC(:•x1�Cd5ii' ,�CV0.�8Y`"•"a •I'�i�Te"��L�'E�E � r' �1�f���� <br /> s <br /> Y.............._....... ........................... .......................... ........,............... .... .. ..... ei... ..,............ .. ....................... ............... <br /> �.rx.•.swray aewriw.,wew»asxw�..o.r»xwmsm caaee• :eaaa v!::w:vae:aw:.,^•<s:�»:o... tw,.+rotxaor:<;aw,n:r.�...u::reM:+xo'rxi s� 4r:<.,r:«..;.rr:.ix+r xw»..e.ww wa.w ww..wr.o..wsnw wn:+s.c•wu.r.a� <br /> �d1119G7t9I� A�Y AYW6➢AtiiWdlsltbK 2L1i�LY3C"Y 1L�,:AYi:+•:w:Y:Y'' }?.Y:S`.3::.:vY.;^.9.L:;�:�`,Yui:#.�:.:5::::.:`.�;:h>,v'ic:;,",:::Y...:'r".w.Yi:;Ss`"••JY:1.':!'�i:`.^.Y..'."�dti�ARiti A1Pf 28'O�i➢AAF%CNi:Wfi1N��9R1�Y+1�� <br /> cw 7c nil roKv s7/;)A/Of11 fr Pace 11 <br />