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' SA.V JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> I FACILITY SITE NAME CNeVeoq !2 Q 964 FACILITY CONTACT NAME �N41ki <br /> I.rIG r CJ �7 _l , �itV y '�'.H(.E 14�I� <br /> T �A ,.'`�n n� SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS �' 00 YU+'►I LL—b eo 20q q5� Z��i <br /> & Yii+'►1`G'I� STATE ZIP CODE # of TANKS 1 <br /> CITY �4 Co. I °IS�s kat SITE �GG ��Cr Q� p <br /> A <br /> P APPLICANT/BILLING NAM APPLICANT CONTACT NAME <br /> L 6t20010 GP,Q.►C1 `YA4X-O?. <br /> I APPLICANT PHONE # WITH AREA CODE <br /> CA MAILING ADDRESS �'�� 4, M��Dower g • "TYPEof <br /> 1b6D <br /> N STATE IP CODE ICATIONTCITY �.�YH4 jd. �G .4qt stallation, etc.)j4fk&Cf6• Z S <br /> l t�pSvAi✓ 'N) Ci -tDIS�1-`NS��S TOTAL <br /> A TANK FEE _ $50.00/TANK (Prior to January 1,1991) 5170/TANK (After =25287 <br /> T # Tanks = 1985 j 1987 1988 11989 1990 1991 1992 1993 <br /> I (multiply fee for <br /> V each year app icable) XXXX 1 XXXX XXXX XXXX XXXX <br /> E TANK PENALTY FEES ASSESSED I XXXX I XXXX XXXX XXXX I XXXX ( <br /> S <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Code, <br /> T 198b through 1990 1991 throu <br /> E # Tanks x $56.00 <br /> (Enter amount and year) I $ <br /> X Y- <br /> LETEMPORARY <br /> MANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) �"" <br /> SURE FEE _ $78.00/hour (3 hours minimum/TANK) I # TANK(s) X $234.00 =LL $ 3{O <br /> TANK I.D. #(s) <br /> PORARY CLOSURE (Plan Reviews Inspections) y <br /> $ <br /> CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) - $234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> $ <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E X $234.00 = $ <br /> P TANK LINING REPAIR FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) <br /> A $ <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br /> R = $234.00 minimum S <br /> PIPING REPAIR FEE _ $78.00/hour (3 hours minimum/FACILITY) <br /> M TRANSFER FEE _ $20.00 ( UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br /> I <br /> S $ <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr <br /> TOTAL DUE <br /> T!4 C- cl <br /> :-.«--_ <br /> r' !- <br /> ;.;::.-..�5ui:�PS—'#�'" OOM�l71`�k•�–Lbs«��Ob��bl$T I;OD� AMbUN"I�ft�CE'IVEb �Fi�t:1�3T/t:ASH <br /> . Ip ;•tI <br /> ...».—. _»...... .........» .. s: :..--::e:cr..—.^.r. :p.. _..... :.«r r• ec::.::�:::.rr.•xsv_--:a»�:.-n::rrrse•Y^rs:_.„,....u.». .«..»..s........._....« <br /> 111•....»:.:..r.:ns.•�:•:........_...s........rs....._....::srr.«...:sr.::r.:r.»..;.....-- ..+._..«...:_........—......_....r»:��. ._....—....._.._.».............._»....._...:::�.x:�::�.:::x•...:±....._;.»—._....._.. <br /> EH 23 046 (Revised 9/11/96) Page 11 <br />