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t M JOAQUIN COUNTY PUBLIC HEALTH SERVICES is <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> tF 41 C eq ��L�C <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L So-F G^ Qj <br /> I <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y z f at SITE <br /> A APPLICANT/BELLING NAME APPLICANT CONTACT NAME <br /> P <br /> AI <br /> ILING ADDRESS APPLICANT PHONE # WITH•AREA CODETY STATE ZIP CODE TYPE of APPLICATION <br /> �1r CLOSURE, INSTALLATION, etc. <br /> V TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I $ <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) _$170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1 1988 1 1989 1 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) 5 <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 $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = $ <br /> 0 <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 = $ <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum TS <br /> R REPAIR 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 REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> ..............................................................:............................................................................................................. .... ... .... .......... .... .... .......... <br /> NQO%00 JC0000%OP)l p0pp 10001aew0)pOP%00 foP000%OD'FW00]0.'PM\P X<O:WGi6 X<P xS4:V-•:�:P:h x«O:O:C X.Xi�•:•:i4 x•:J:•xi•:•}:•??:•::•??:•}:•x�.??:i:•i i}J:}:�:+P::iP:•:J XS�M:tNO:oaOXM xK•:O)000%Oo%o00P%00%%VO%Oi]000P>%ii%OWO%00�P IOOOOP 1000#00 <br /> »s'$ t Pa ' COt r ' air . .a I'IxST`�CCISE'? }isAhlOUtiT'RCV0:•?;•::?x::''ME CK... <br /> iIS'tl' RCW X81 } } C f�E WRIT' ' <br /> ,CK ZZ 5 lr� �R� z�� r. <br /> 7g0a......x<ae zooia0000 zaaaa%oii zae loiiialoOP xa000zoo XOoO>:iMiOki iOOCio:po:NfM ri^i{iMY::K•xN:d!4i:<:+. ?:StO v.v;o}Xti i:!O iliii0: boo xiicoicoo i000 i000ea i000 i00000 i0oo zeoaP>aoo zeeei xoe zoi zooeiioaa za$s <br /> >mAG7 imDY9S aa0YQX�i>1FA6 7�5Rmi 2A7f SPS}�L7��15:C:A. :>.Y.iS:.,Jf.^.Y:}Y:SS L:2�:L`Y^.;•.v`.;`::;^ .........•..........•........: i:^.?rte >1XS A«LL::SQiIYdG APoY ILDDDg%qi ow WN WA xx AtLbS>D >b <br /> Cu 9Z nZ7 /DCV 19/9A/Oni ft Pnae 11 <br /> e <br />