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a JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 1CITY STATE ZIP CODE # of TANKS <br /> T <br /> Y l .� � at SITE <br /> A APPLICANT/SILLIII NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> ! MAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> _ l <br /> C <br /> A C � - <br /> N Y STATE ZIP CCDE TYPE of APPLICATION <br /> T ti, ,�\ �,��J�� CLOSURE, INSTALLATION, etc. <br /> �_Q _ <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 $ <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F 9 Tanks = 1986 1987 1988 1989 1990 1 1991 1 1992 1993 1 1994 1 1995 1996 <br /> A (multiply # by fee for <br /> c each year applicable) $ <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> l <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> $ <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 = 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 # TANK(s) X $150.00 = $ <br /> P PLAN CHECK (Install. Pian Review & construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) _ $424.00 minimum $ <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 = S U(i <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE = S53.00/hr FEE = $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE 1 $ 59.0 <br /> OFFICE USE ONLY <br /> ........................,..............................,.,.........,....:.............;..;..;._.,.,,::......:..,..,..,;:•:';:•:?':;.:<.:>}::'F:':::?Y??::.:[:ra:.{.....;.....:..coiw'ico:cec:'o:ioo i«id iow'ao iooa iootiei eoo»avmo Goa:>:oeea ludo ioa:;o.00P oac isa6 <br /> i1P0IP)Pp.40F>OW%<OW)4W10000P 00f9X«01000N)P)b 100PA 1W0 w<lP«P<a4.P`S <44 NnfS A?t 9Ys� 'J Y •� '�00' ` ... <br /> »AVEWS14 Ir ''Tree" ..,....AfaauiR.f�..:s:.. .cHEcx...��cas�H.Y,R��rY�YH .��ES2�L�I�(� �c r Fh�LI ;F <br /> g <br /> ..................... ............... ...... ... .... <br /> M0►%M 0000000000000000+000)0001P%Ntp<01mwe1000%VOV.1000>COlOP"P00'C0«>`VA. iCPi-.P4 K•'fa• S RP O N its f P <i< %00%0P NN00 Pn0 iP aM,iPa Wx 100000]➢.0 J000 H4VOP AV0Ii4 <br /> REYOY 17gysL�Yfagi%�37i Rtsi�i�AF RP�i fB2to7F <br /> cu 7i nz'> focu S7/7(,/9t11 ft. P.1aa 11 <br />