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�AN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> 1FACIL ADDRESS SITE PHONE # with A CODE <br /> Cao l - 87�s <br /> T CITY S ATE ZIP CODE # of TANKS <br /> Y 5 1 <br /> at SITE <br /> A APPLICANT/BILLING NAME _ APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY gTE 21P CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> FACILI1 ��J TOTAL <br /> A <br /> C _ 990 1991 1 1992 1 1993 1 1994 1 1995 1996 <br /> V � JA EOV(J <br /> E TANK FEE ^ <br /> F # Tanks AC�� �0 1991 1992 1993 1994 1995 1996 <br /> A (mu l t ply <br /> — 6D1 each year $04'z <br /> L STATE SURCh \ T ' \ ODE, Sec 25287 for applicability) 6 <br /> T # Tanks o`Z 1991 1992 1993 1994 1995 1996 <br /> Y (enter emoun <br /> PERMANENT CLO_.,... (Removal or Closure-in-place) <br /> C o <br /> L CLOSURE FEE = $90.00 each TANK # Tanks a. x $90.00 A Ig v <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> R <br /> E TEMPORARY CLOSURE FEE = 580.00 each TANK # Tanks x $90.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) 5 <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each SUBMISSION/RESUBMISSION # Tanks x $110.00 5 <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minim m one hour to be paid on plan submittal) <br /> 1 <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 530.00/hr FEE = 535.00/hr FEE = 535.00/hr $ <br /> TOTAL DUE S/VQ <br /> OFFICE USE ONLY LL�� <br /> w e o e.w m vFi a o u m a e�m e z n m x e a a»o z o o x w w a <br /> o.. .... qa ....o. ......... a .. ......... $..............................I. <br /> FH 23 032 (REV 6/90) ft Pape 11 <br />