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JOAQUIN COUNTY PUBLIC HEALTH SERVICES • <br /> ENVIRONMENTAL HEALTH DIVISION <br /> t UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME <br /> FACILITY CONTACT NAME <br /> .F _T <br /> L ' !le r e l eee��r <br /> 1 FACILITY ADDRESS SITE PHONE # With AREA CODE <br /> I <br /> 9 No. <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y at SITE 79 C <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> LP IV/ <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C 02 <br /> A <br /> N CITY I ST E ZIP CODE TYP APPLICATION <br /> T G / LOSURE INSTALLATION, etc. 6L/' <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> 1 f <br /> v <br /> E TANK FEE = 850.00/TANK (prior to January 1,1991) 8170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1 1995 1996 <br /> A (multiply p—by feefor <br /> C each year applicable) 8 <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> ( <br /> T # Tks x $56.00 1986 through 1990 1991 through 1996 <br /> Y [z(enEr amount and year) <br />` f <br /> 1 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK 1.0. #(s) <br /> C <br /> L CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ K 8159.00 = f <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) _ X $150.00 = f <br /> P PLAN CHECK (Install. Ptan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (B hours minimum per Facility) = $424.00 minimum S <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minimum/TANK) # TANK(s) % $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = 5159.00) f <br /> M CONSULTATIONS _ UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C I FEE _ $53.00/hr FEE _ $53.00/hr FEE L! 53.00/hr <br /> TOTAL DUE S za.90 <br /> OFFICE USE ONLY <br /> ............. <br /> x es <br /> TM FV%WT TaTOV FP RwV.OM MM AmJ%p:WINFO%fi0%(4%P'i0%<G:tlM:u4N Y%"%hW:0t4:<.i%0:[tir:tt4:nq'4N:0'IRPV S%4:.%Y.Y:tk'FY.N:fM%.'J%P+W Po'Aw0 WWMMaN.V»aAuy as AVN Ap xm zxM Mev <br /> '3kMIr' COM�Vmrdcas'w)' LOZ;""CO�1� avIST..�.�E:s.l,s.if��017H7•.R.CW._•x"i•t'ffECiC"�/'C'd5aH...;s.��2�CV0'nBYz'�V�TETME'r'mr° 1�1'Tr'xs s <br /> = I. 1. ...........1.. $ ts9.. °° 3�i3 mrZ, .� <br /> ..................... ....................... ........... ......... .....,.. ( g <br /> �NYIDXiAlfq�i[d3fAtYAWY AYiRA'Ak1D'#%�l'cYfsX rXP.Y:A`iX'::.Y""' JYACY 9.:.X�.".YRL`2iS'X.�.X:w�:.,.:h<."iaYFR:.`" `Y:'>...:r,'..r.�RL`AY91#` u`,yX:Y:iAY%tST AMt IDmM mtARl4i Ytl(AYPY AMi MY&iIY�V'6i% <br /> cw 71 nse rocV IPDA/9nl fe plop 11 <br />