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OAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> z3n 8r n <br /> I FACILM ADDRESS SITE PHONE # with ARIA CODE <br /> 11 7 a C ao l - �7f1� <br /> T CITY V17STATE ZIP CODE # of TANKS <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P SCPiYYc 2� <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1 1987 1988 1 1989 1 1990 1 1991 1992 1993 1994 1995 1996 <br /> T <br /> I l A� >2ro Od s <br /> E TANK FEE _ $50.00 each TANK <br /> F # Tanks A x $50.00 1986 1987 1988 1 1989 1 1990 1 1991 1992 1993 1 1994 1 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicabte) <br /> I � <br /> � — �� aw- ate— <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH & SAFETY CODE, Sec 25287 for applicability) <br /> I <br /> T # Tanks a x $56.)0 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> Y [(enter amount and year) <br /> l/a" I I I $ ra " <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> C <br /> L CLOSURE FEE _ $90.00 each TANK # Tanks x $90.00 E <br /> 0 V <br /> S <br /> U TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $80.00 each TANK # Tanks x $90.00 $ <br /> P PLAN CHECK (Installati on or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION (1st 2 hrs. of review) s <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each SUBMISSION/RESUBMISSION # Tanks x $110.00 $ <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, mini mum one hour to be paid on plan sutmittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $, a <br /> OFFICE USE ONLY <br /> " ' .•.•••••.•••••••••••••...••................•..••.......••••••••.•••••••••••....••..••••...•....••••.••••••"i>zeoiaeoz'ewewio»oiiezeezzwae:ie'aeewaewee»owezeee»z'a'eeze......ee»zea......ee»»zi>ziz>z'a6»oe <br /> ww me ww»ww www was neeee xae was waaae was aawee ne.»xe.wo waw ww wee wwee xee wweo wee www aw a ww�weeo woo <br /> a S L 3 -smC AT` NREF.. ' Lfffr-fr s <br /> .o.l... .... . .... $ = <br /> II .• dwe �"' ' ieaeae wee w'aeoeeaoe waeezw � zowewwwaeiewee weieeie»»w»eaeeiiwweweweo»zuiwe»zu z»zS»oe: ..•••.. <br /> ......... .... ........................ ............... <br /> wwwweo eeoe was wam wwao wwwww wro www wee aeeeeo was w=eawm weeee»wwziwwezwww <br /> FI 23 032 (REV 61901 it Pane 11 <br />