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JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> JJ, uG���, 4'sr <br /> IFACILITY ADDRESS SITE PHONE # with AREA CCOE <br /> I STATE ZIP COO E # of TANKS <br /> T CITY 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 STATE ZIP CCAE TYPE of APPLICATION <br /> T CLDSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 7989 7490 <br /> T ANNUAL FACILITY FEE (prior to January 1, 1991) _ S100.00 <br /> 5 <br /> 1�1'D ri?Z;) f tJlJ !au !Uc i <br /> I L�p� <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = _ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (mattiply # by fee for <br /> C each year applicable) s Cz - <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> s 336 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> G <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = S <br /> 0 <br /> S <br /> JULTEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. #(s) <br /> ETEMPORARY CLDSURE FEE = 1150.00 each TANK # TANK(s) X 5150.00 = S <br /> P PLAN CHECK (Instatt. Ptan Review 8 Construction Inspections} TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - s53.00 per hour (8 hours minimum per Facility) - $424.00 minimum $ <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = 553.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = s <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW S CONSTRUCTION = 553.00 per hour (3 hour minimum per facility = $159.00) <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = $53. C/ FEE = S 53.00/hr <br /> TOTAL DUE S r �� <br /> OFFICE USE ONLY _ _ crG.". <br /> .................................................................t .......,....... .......... <br /> ........... <br /> . <br /> ................................. <br /> „.arrolirar.. .C,V : ., ChECK'#iC:isT: ,.RC"n aY C c RC eIiEe `m” ' 1'I <br /> y 5 <br /> ow 7Z nz7 r®cv 1J17AXn1 ft P,zaP `1 <br />