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•JOAOUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME <br /> F FACILITY CONTACT NAME <br /> 1 FACILITY ADDRESS SI <br /> L SITE PHONE Y with AREA CODE <br /> 1 <br /> T CITY STATE ZIP CODE <br /> Y / of TANKS <br /> at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> ,� <br /> NCFI'URT / A /Cti AUSS �r�h°�/t SCt C <br /> I MAILING ADDRESS APPLICANT PHONE M WITH AREA CODE <br /> A 7JS� C U.aK 805 - 9z3'N CITY <br /> STA E ZIP CODE TYPE of APPLICATION <br /> T S�1ti r�1 /YAp!r1 43 y y CLOSURE, INSTALLATION, etc. OAVO//'- <br /> A TOTAL <br /> C1986 1987 1988 1989 1990- <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> I <br /> V = <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TAMK (after January 1, 1991) <br /> F # Tanks 1986 1 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply W'- fee for <br /> 1 each year applicable) _ <br /> L STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H i S Code, Section 25287 <br /> I <br /> T M Tanks z 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> i <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. !(a) <br /> O CLOSURE FEE - 253.00 per hour (3 hours minimum per TANK) M TANK(s) X $159.00 • f <br /> S <br /> R TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(a) <br /> E TEMPORARY CLOSURE FEE - $150.00 each TANK k TANK(c) X $150.00 • S <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspectl ons) TANK I.D. !(a) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimus per facility) • 3424.00 minimus 3 <br /> R REPAIR FEE (workplan review 8 construction inspections) TAMC LD. !(a) <br /> E <br /> P TANK REPAIR FEE $53.00 per hour (3 hours minirtuNTANK) 1 TANK(a) <br /> A .,2 Q X 3159.00 3 vo <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minim per facility • $159.00) 3 <br /> M <br /> I TRANSFER FEE $20.00 UNAUTHORIZED RELEASE EVALUATION • 353.00/hr 3 <br /> S <br /> ClCONSULTATION FEE = 3$3.00/hr SAMPLING INSPECTION FEE • 353.00/hr 3 <br /> TOTAL DUE 3 31 $0 .oa <br /> e <br /> a._ 0C <br /> . .. era . <br /> SLEEPS YCfnPUTC'k iC'ODEIbl5T CbDE AMbI)N CSD CGCG dEGEkO� '����`biCTE�RECEYVEti° � <br /> EH 23 032 (REV 4/8/91) ft <br /> PAYiAEN r <br /> RECEIVED <br /> JUS! 0 5 121c? <br /> SAN JOAQUIN COil"1Tf <br /> PU3LlC HEALTH SUvb_:`S <br /> ENVIRONMENTAL HEALI H Oi';: <br /> 9 <br />