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JOAOUIH COUNTY PUBLIC HEALTH SERVICES • <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> Naval Re5erve Ce-,�-der Ll � ��fon �20� )��1y-05 <br /> IFACILITY ADDRESS ITE PHONE # with AREA CODE <br /> o C-o 4-e- b t OL C' <br /> Tf TA <br /> CITY �. �A� ZIP <br /> CODE�jZQ3 atoSITEHKS + Pit � <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAMEA Y <br /> L 1ede I b-nvironwental �'rVtu_ ', eGt� K 1 J p 8 f ; <br /> 4Cli y <br /> I HAILING ALDRESS ;�� APPLICANT PHONE # WITH 4R€A COOL /V r4 <br /> �11a`1Jl <br /> C � �g �C� K��) J C-�cc 1�JY( l/� /5 ) z 2 Z — ) <br /> N CITY � � �j STATE ZIP CCA APPLICATION <br /> T ! C� C !� CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1985 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = s100.00 <br /> 1 r00 /00 (04) fc)o /©U s <br /> V <br /> E TANK FEE = S50.00/TANK {prior to January 1,1991} 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1985 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (muttiply # by fee for !� <br /> C each year applicable) 5� i7D `5b C5V 7 S /La <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See CaLifornia H 3 S Code, section 25287 <br /> 1 <br /> T # Tanks_ x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 561 5� S /lZ <br /> PERMANENT CLOSURE (Removal or Authorized CLasure-in-Place) TANK I.D. #(s) Q/ <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)—j ,_ X 5159.00 S P�y j 4)" <br /> 0 <br /> Sl <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK # TANK(s) X 5150.00 = S <br /> P PLAN CHECK (InstatL. Pian Review b Construction Inspections) TANK C.D. #(s) <br /> L <br /> A <br /> H PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facitity) = $424.00 miniaun S <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X 5159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = S53.00 per hour (3 hour minimum per facility = S159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING 14SPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE = $53.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE S [� ` <br /> / 32 <br /> OFFICE USE ONLY <br /> :YlYYlYr 1Y.aMl,INlJ�wl.�.N AOwiaa>:ioasV:A.\l:aN:i./F4\iS:Ad"+trt'�i.:i:1<;::a:O:J:i.inv;v:�i:.:•}`:f:;..Y:b:.+::rr:i=}:'.i:.:..;.} •••••••• ,•••••••• •-••.••••••••••••••••• <br /> r jOtit4 til:ORa! .Ai I.w/Mwfw.�.w.1�A lMV�iwl Y�a.w'o�. <br /> xc4Zy`" cHECX�9/CAS'H's>, c4D sgy:-: 15`�k WIT 5=4 A"� <br /> Y., 32 5 <br /> r..�r.�..w.w•.w.wr wl seloa..i.o. wu eaw:aw:wao x-. .r e.�l: -o:<a�.:;u•xe•,:,e.a:•:t;v sxt=:» :......a...:a.+..ra;r.+�n.l:rlwawl,a...w.s.al xrrr.r`rri..w.......�rr..r.ar aa. <br /> wo AN AUX{ TA'ArfAMWOO W*WW"XA2i►1LY'Fs.Y�}.7Z4W,S`..'.°.5'."..'3rr:Y.'.:'t>.5:.:7 e�:::Y:..:.:;LhS:';�:�.::.:" �;: .,.,�;::1'J•'St.:�7fi��^L^.:di"AWW.4W ZMW Am Ama WXAMW A/iX 231.1{AS.SX <br /> cu 7Z nZ2 rocv 17/7AI9n1 fr P�aa 11 <br />