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• SAN JOAOVIN COUNTY PUBLIC HEALTH SERVO <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERCRCUND STORAGE TAW PROGRAM - FEE WORKSHEET <br /> F FACILITY SITE NAME 8/LL PA.eX.s AFACILITY CONTACT NAME <br /> A G <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> T CITY '�- STATE ZIP CODE # of TANKS <br /> Y 6 at SITE 4 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> n <br /> N CI Y ST TE ZIP CODE TYPE of APPLICATION LGl2vle2— <br /> T O� C' CLOSURE, INSTALLATION, etc.����� <br /> C TH <br /> 1987~ 1988 1 1989 1 1990 TOTAL <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00/YR. <br /> 1 <br /> E TANK FEE 150.00/TANK (prior to January 1.,1991) 5170/7ANK (after January 1, 1991) <br /> F # Tanks - 1986 1987 ; 196.`, 1930 1900 +991 1 1992 1193 1994 l 15>95 <br /> A (PJttfoty u by fee for <br /> C each year opp(fceb(a) <br /> L STATE SURCHARGE c $56,00 each TANK (Due every 5 years) See CsllROrnfe H 9 S Ccde, Section 25287 c%[� <br /> # Tanks x 556.00 1986 through 1990 1991 through 199d <br /> Y (enter and and year) ---- —•- �.�_.._._. <br /> PF.RMARENT CLOSURE (Rxrovat co _ A4K 1.0. #(s) <br /> L CLOSURE FEE • $53.00 per hour (3 hdjf8 minimus 1.e, TANK) I K TANK(a7-l. X 5759.00 <br /> p Y.,. <br /> U TEMPORARY CLOSURE (A ona•tira permit, for revi cw/inspe:Cons) rANK I.O. #(s) <br /> R __._ _—__--A�_��� ----- — -- <br /> E TEMPORARY CLOSURE FEE • $750.00 each TANK a TANK(S) X $150.00 S <br /> P PLAN CHECK (Irstal(. Plan Review & Construction 'e-c tt:ns) TANK LD. #(a)--- <br /> L ._.e. <br /> A <br /> N PLAN CHECK FEF. - $53.00 per hour 48 hours minlrlri r r Fs:i(ity) = $424.00 minlatn <br /> R REPAIR FEE (workotan review & ccnstruc-ivinepacii -rt) TANK I. . #(a) <br /> — <br /> P TANK REPAIR FEE ,. $53.00 per hoar (3 I)OW9 ninimjlg'74NK) ( TANK(g) X 5159.00 5 <br /> R PIPING RFPAiR FEE = 353,00 per hwar (3 hVJ' nirincn per `zcl;fty = S159.00) 3 <br /> Hl C04SULTATINS UNAUTRPR1,'El. FELEASE EJAi0ATI0N SAMPLING IIISPECTIO.N ��' •*���' <br /> 1 1 <br /> S <br /> _ <br /> C FEE - 553.00'hr FCC 5.53,001'+r' FEE = S 53.00/hr <br /> TOTAL DUE LES <br /> / '?2A�0� <br /> OFFICE USE ON�y __/=d R� <br /> •,in .�., <br /> wro%fapm:, •+:. >r n.. .... uG w-rnwrr»»yea _. <br /> -C"'t u� 4Y" <br /> gym'1 n».:.»vw - .wvT.»:�• ra,r »ie.yu K.w :ww w. <br /> }L'1 GW Po1'ar AY f+A:G 1. ....Y i. {.::4'.:'lX/:.Y yW/ rW1 YYJ:1'f r.Y" .,n.C.a�.:� .a_i.2..��MkM1:kk'iYw.4Y'/MVsw�d':W'Tf.....#gMpAMM3'dP?M.K1,5''A1Y�M.\W/!4 M•f MYfPYMftM MIF TY LSt::d <br />