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AN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F / _ / <br /> A �.!I '' �// r .-� rrYX <br /> C <br /> I lALill Y ADDR$R �, /� • ITL P ! M With AREA CODE <br /> I � � � i tJ c; rw > .�� 0q <br /> T CITY `,� STATE ZIP CODE N of TANKS <br /> Y J t' ck c1.7J �' �� �� at SITE / <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P f C' <br /> L <br /> I MAILING ADDRESS APPLI NT PHONE Y WITH AREA CODE <br /> STATE ZIP CODE TYPE of APPLICATION <br /> N CITY —`- <br /> T 'pc-./�-�j,nl (' c� �� CLOSURE , INSTALLATION, etc .� 7 F' C , <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1 , 1991 ) • $100 .00 <br /> I i <br /> V <br /> E TANK FEE • $50 . 00/TANK (prior to January 101991 ) 5S170/TJUIK ( sf Ser January 1 , 1991 ) <br /> F B Tanks • 1986 1987 1988 1989 19901992 1993 1994 1995 1996 <br /> A ( multiply fee for <br /> C each year app icable) 7D. S <br /> 1 <br /> L STATE SURCHARGE • $56 .00 each TANK (Due every S years ) See California N i 5 Code, Section 25287 <br /> 1 <br /> T }! Tanks x 1986 through 1990 1991 through 1996 <br /> Y ( enter ofmnnt andnd yyeaear) <br /> s 2C <br /> PERMANENT CLOSURE (Removal or Authorized Closure- in- PL ace) TANK I .D . Ks) <br /> C <br /> L CLOSURE FEE $53 .00 per hour 0 hours ■Iniaz. per TANK) M TANK( s )_ % 5159 . 00 f <br /> 0 <br /> 5 <br /> U TEMPORARY CLOSURE (A ons• ttme permit , for review/ inspections ) TANK 1 .D . /(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • $150 . 00 each TANK r TANK( s ) % $150 . 00 • $ <br /> P PLAN CHECK ( Install . Plan Review t Construction Inspectional TANK I .D . i(s) <br /> LmZm <br /> A <br /> N PLAN CHECK FEE - $53 . 00 per hour (8 hours minimus per Facility) $424 . 00 mi sinus f <br /> R REPAIR FEE ( Workplan review 6 construction inspections ) TANK I .D . /( a) <br /> E <br /> P TANK REPAIR FEE $53 . 00 per hour (3 hours minimum/TANK) / TANK( s ) x $159 . 00 f <br /> A <br /> R PIPING REPAIR FEE • $53 . 00 per hour (3 hour minimus per facility • $159. 00) S <br /> M TRANSFER FEE • $20 . 00 UNAUTHORIZED RELEASE EVALUATION • $53 . 00/hr S <br /> C CONSULTATION FEE $53 . 00/hr SAMPLING INSPECTION FEE a $53 . 00/hr $ <br /> TOTAL DUE f 90 C v <br /> nummaaRmmxammm^.:9nreu. re, .m:r:m:: H <br /> c:_�sa�` :; :;;: <br /> ' ' C`�b' �- " ">� � . "t�i�'mma,�� : <br /> EH 23 032 ( REV 4/8/91 ) ft <br /> 9 <br />