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t �rA JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> 'tNV1RCNMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CYN ACT NAME <br /> A <br /> C <br /> I FACILITY ADDRESS SITE PHONE 9 with AREA CODE <br /> L 2l 5 r�et..ht <br /> I <br /> T CITY STATE ZIP CODE of TANKS <br /> Yat SITE <br /> A APPLICANT/BILLING NAME \ APPLICANT CONTACT NAME <br /> P <br /> lc rn L l�� � a3 2,ey <br /> L <br /> I HAILING ADDRESS APPLICANT PHONE I WITH -AREA CODE <br /> S Sfre�` z �y - 583 - o zv/ <br /> A <br /> N CITY S TE ZIP CODE TYPE APPL C�T_1 <br /> T - Q 3 23G OSURE STALLATIC etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> I S <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) Ft 170/TANK (after January 1, 1991) <br /> F 1 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1 1994 1995 1996 <br /> A (multiply 0 by fee for I I <br /> C each year applicable) S <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H b S Code, Section 25287 <br /> I <br /> T 1 Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 5 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. 1(s) <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimun per TANK) I ; TANK(s) X 5159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review E inspectiont TANK I.D. °(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK 1 TANK(s) X 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review S Construction Inspections) TANK I.D. �'(s) �/f�v (O <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours mininun per Facility) - $424.00 minimum S <br /> R REPAIR TANK I.D. :(s) <br /> E <br /> P TANK REPAIR FE=_ = S53.00 per hour (3 hours minimum/TANK) TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R I PIPING REPAIR REVIEW d CONSTRUCTION = 553.00 per hour (3 hour minimvn per facility = S159.00) S <br /> M CCNSULTATICNS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFIC-c USE ONLY <br /> _ _ ........ _ `:ar <br /> -�—� J— <br /> =r5 I C�4P �` OC?CCi7c '7iii-'CCAt I AA1CUlli RC - c�.< C SnrY� `zt=Fvaa=v a �s�nr sQ <br /> .D i ,.n _ ,.J Kt�clvcu rtnhl - <br /> a <br /> .... - - ..--........._ _---......................1_ <br /> ....._..1.s...................._.. <br /> .......................... <br />