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%W AN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> .FACILITY SITE NAME FACILITY CONTACT NAME <br /> I FACILITY ADDRESS , / /�!� SITE PHONE # with AREA CODE <br /> 1 <br /> E 7 <br /> T CITY STATE} ZIP(CXE # of TANKS <br /> Y J L� e' ,3G � at SITE / <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> azo <br /> L <br /> CMAILING ADDRESS ! APPLICANT PHONE #'NITN,AREA CODE <br /> A <br /> NrCITY -APPLICATIONSTAT ZIP CODE INSTALLATION, etc. <br /> T <br /> TOTAL <br /> A <br /> C 1986 1987i 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991-)..= $100.00, <br /> I S <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,199 1). ` = 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1 1991 1 1992 1993 1 1994 1 1995 1 1996 <br /> A (multiply # by fee for <br /> C each year applicable) 5 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T ' <br /> T # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> I <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 niihimum per TANK)Y # TANK(s) C $159:00 = - - S O <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, forxrevieu,& inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK 1.0. #(s) <br /> L <br /> A <br /> N PIAN CHECK FEE - S53.00 per hour (8 hours minimum per Facility).= $424.00 minimum S <br /> R REPAIR TANK E.D. #(s) <br /> E <br /> P TANK REPAIR FEE = 553.00 per hour (3 hours minimum/TANK) # fANK(s) X $159.00 = S f <br /> A <br /> L <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = S159.00) S t <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE: <br /> OFFICE USE ONLY <br /> ........................................................................_........`_.,;•:•::.........:.;;;.;':.�::.:•-?.:='-;.':;::: :-...:..,;,:._..,..;._.,..__...,a......... zoos ioe>zeae woo ioo> <br /> ww wb weeoo xoe wcaae xea s�..ewroww xo�o-wee wawa w.+e xa�a:ne.wv.aEs tit..w.xa s:aa.e . „s a a.,a«+crs�<o;«cw x'ee>ecus:ioo ima xaoei irooioeeea Tsai zamicoe ieeaas <br /> s <br /> S�7E P5' OT "'LOC""C00T� " `DiYST"CCZ3E: altiOlilaT RC' 5 Ci ECK"#/C ' r�,)`I'f g <br /> . <br /> AM)ew Mixte law]ot.WY l000Xm.]�vee»weeiwofeaaeo wookd.VP:tN?Kd.S:^'O:Y9:M^tP:MS:t"'M`:"5:i:?�'i:?N:'N.:it•r.-:tia:va:n:.v,,v;nv,.:t'.rf`:.•???'r.rr;p xte:ese:aae •••%90 idsi�%�PimOOO MM•� •�Y�rA00%M%OOW P�xos <br /> f 9Ati iPVF �RKR fl�f6 A371 AS5WF RbS AbJt.'f �]L7S A)f'.v:'.`i: .):i'Jf ':4�:3.`S AM", <br /> ru 77 nz") rocv 1;11?Aionti ft, P.naP 1,1 <br /> c <br />