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t <br /> ._,A JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> a <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WCRKSHEET <br /> FFACILITT <br /> LITY SITE NAME FACILITY N ACT NAME <br /> FI ! e�� �G� eis `�1� n ADDRESS SITE PHONE 9 with AREA CODE <br /> 2 f 5 �resrierLf- 5�- <br /> Y CITY ��L9 STA 7E ZIP CCOE a of TANKS <br /> �f at SITE <br /> A APPLICANT/9ILLING NAME APPLICANT CONTACT NAME <br /> P <br /> U f arc m 2� L 1��� t wad <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 0 WITH-AREA CODE <br /> H CITY ✓ � S,T,�TE ZIP CODE TYPE APPL -CAT.I ON <br /> T (V¢ 7 3 Zed OSURE STALLAFCO etc. <br /> A TOTAL <br /> C 1986 1987 1988 1 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> I <br /> V <br /> S <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 1 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply 0 by fee for <br /> C each year applicable) I I I S <br /> L STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> i <br /> T 1 Tanks x 556.001986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. �(s) <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimLn per TANK) I TANK(s) X 5159.00 - S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review b inspections TANK I.D. 1(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 5150.00 each TANK 0 TANK(s) X $150.00 = S <br /> P PLAN CHECK (install. Plan Review b Construction Inspections) TANK I.D. 9(s) y , 15- 6- <br /> L <br /> A f O 5 x 3 - 6"2, <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimzn per Facility) - $424.00 miniman S yZ`/cam <br /> PATANK I.D. :(s) <br /> E <br /> IR FEE = 553.00 per hour (3 hours minimLm/TANK) 9 TANK(s) X 5159.00 = S <br /> PAIR REVIEW E CONSTRUCTION = 553.00 per hour (3 hour minimum per facility = S159.00) S <br /> MFCONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE-= 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S 2 <br /> OFFICE USE CNLY <br /> �—z ����,.Qom.._ :>- - - «:> _ ::>: _ <br /> LTi r =,.Y.... _ - - <br /> is ��LOC CCO 0i�� �C,()i_r AAICUN7 RC':i3 I el �i'Rry <br /> _ I <br /> D oYE R_�clvcu rcrtMli - <br /> I - - <br /> ._...._................ _._........_...._.. .5..... .� <br />