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�JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNOERGRCUNO STORAGE TANK PROGRAM . FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F Navy R ,serve Ce,vi ef- L� g2�'fon (Zoe)lyy-o5/ <br /> A <br /> C <br /> I FACILITY ADDRESS !TE PHON # with AREA CODE <br /> L 3100 on� � ��a IC Av�nJ� 2oq 9y4 - i� <br /> T CITY STATE ZIP CCOE # of TANKS - <br /> Y :!5tMBIL n C.� 5Z o)7 at SITE I /` <br /> A APPLICANTIBI•LLINNIG NAME APPLICANT CONTACT NAME <br /> P Rlede. � �nviYonmental S�1-vl �s R. 5�t4 K / Op <br /> L <br /> I NAILING ORESS APPLICANT PHONE # WITH-AREA CO <br /> 138 LaKeSidt; � ve ( /5) z2z - iv <br /> A <br /> STj TTIE ZIP CCO APPLICATION <br /> CITY <br /> T INSTALLATION, etc. <br /> (• 7 L•� TOTAL <br /> A 1986 1 1987 1 1988 1989 1990 <br /> C <br /> TANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 1Q0 loo1106 <br /> l <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 (sultiply # by fee far , 1 <br /> C each year applicable) S(i 5� 'J� / f S <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 4 S Code, Section 25287 <br /> I <br /> T # Tanks _ X 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> J(O J(O 5 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) 0� <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) At TANK(s)—j,_ X $159.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 4 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TAHK(s) _ X 5150.00 = S <br /> P PLAN CHECK (Instal(. Plan Review S. Construction Inspections) TANK D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (a hours minisum per Facility) = $424.00 minimum S <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = S .00 our (3 hours minimum/TANK) # TANK(s) X 5159.00 = 5 <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 4 5 = 553.00 per hour (3 hour minimus per facility = $159.00) S <br /> M CONSULTATIONS _ UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S i viz <br /> OFFICE USE ONLY ........................ <br /> ........................ <br /> ............_....................................................................................................................................................................... ............ <br /> t�S 77T <br /> L'OC"[C "r>�l' CDE ' 4iCUNT"RCVvcsEc< ./CA s <br /> / 321 <br /> ................................. <br /> cu Ji niP /ocV 17/7A/On1 Fr Paan. 11 <br />