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,(',914 �;!r QN`�'/v � JOAOUIN COUNTY PUBLIC HEALTH SERVICES • <br /> _//05 elf ENVIRONMENTAL HEALTH DIVISION / <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> � �� <br /> I FACILITY ADDRESS SITE PHONE X with AREA COOE <br /> T CITY STATE ZIP CC�WDE/E X of TANKS <br /> Y </�O/PN'ffll�J /�-- �%O� at SITE . <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> I NAILING A00RE55 APPLICANT PHONE X WITH iREA COOE <br /> A Po' 2liv697 <br /> C1STA E ZIP CODE TYPE of APPLICATION <br /> T ��// /_'®-..`r �6�1 CLOSURE, INSTALLATION, etc. <br /> Cir✓ TOTAL <br /> A <br /> C 1986 1987 1 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I mo I/00 y-c>4 '-00 <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F At Tanks = Zi 1986 1987 1988 1989 1990 1991 1992 .1993 1996 1995 1996 <br /> A (multiply p byby fee for <br /> c each year applicable) 'LOU ZtlU "."U1650 16gol I I <br /> I <br /> L �7anks <br /> RGE = 556.00 each TANK (Due every 5 years) See California H f S Code, Section 25287 <br /> 1 <br /> T ->< 556.00 1986 through 1990 1991 through 1996Yt and year) <br /> If L $ 7 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(a) <br /> C <br /> L CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) 0 TANK(s)_ X $159.00 f <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d inspections TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE = 9150.00 each TANK If TANK(s) _ X 1150.00 f <br /> P PLAN CHECK (Install. Plan Review 3 Construction Inspections) TANK I.D. Nis) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 minimun f <br /> R REPAIR TANK I.D. I!(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) S TANK(s) _ X 5159.00 = f <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 1 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) f <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> �3 Ee7�SCOl1V'vil1e �CC'rCO� F"� I ST"C'CUE' `,'Ud`C�111�i•.�C4U:_;s...�CffEC':C" l'Cm'ASH (C`'ib�'9Y'm <br /> r g L a <br /> ..................... ......_«_....._._.. _...._..........._.. ................_............_ .............................. .. .... ....«. ....... ... .._«.....! <br /> im:uaewi:ro.wroo:w i:....�a:::iw 4::.�.�_••••••• <br /> .....� <br /> maa�l si=araiaaaiMv`iaaitaimCiRYa17STY;t9a5]m YSix""..i9.]iSi....l'xYd:Y.:f#.Y:::.:P.a":^,:.^.mkw..�#ti' W11aiJ1iliRMaMAf�il�as AwYii:Ml <br /> vu 71 n17 roev 17/7A/Cnl Fr Pnee 11 <br />