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ON <br /> JOAQUIN CCUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACI_NAME <br /> F ��Ti✓ ieECt55 <br /> A <br /> N <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y ( 95Z. 4 at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P �-- <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> *f I TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> IV �pv1Y S o0 <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991)v(xj#! 5170/TANK (after January 1, 1991) <br /> F # Tanks = __L 1986 1987 1988 1989 1990' 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year appticabte) x FT w t; S 7 oe <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks__ x 556.00 1986 through 199OU�-rril-I Ur-rtL?1991 through 1996 uG i U cr2 <br /> Y (enter amount and year) y <br /> �CE7�1PT iti V." S r_!_ 00 <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) C)C-T is! <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 <br /> 1-0 <br /> 0 v <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = S159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> WOW <br /> TT <br /> xoaxes»oeeexasxamo.xesxoees�aooxes�eeoaexoewoeooxesxowm.zasxoees�eaoxasxoee►xoszeoeoxeswaaa.xaaxaaxowa.xaozowsxosxwamasxoeesxaoxas xoeoexo.�eeae.zosxoa.xeswaaxaeasze►zawoxesmoa►xesxwaoxe.xoaxeaaxes»a� <br /> .2.4.0ol..... ........................ .................... ».. S»—�`�-j ..-».. �so3o,2► L 12J2t� �ia Z�e g1 <br /> ........»..... .�.. ».... !'............... ......................................... <br /> EH 23 032 (REV 1/10/91) ft Pace 11 <br />