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JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ` ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEETS 3 Zy <br /> FACILITY SITE NAME c FACILITY CONTACT NAME <br /> Fg'N� (� r� 2, J�eJl ( C` Q x <br /> A <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> I <br /> T CITY JSTATE ZIP CODE # of TANKS <br /> Y jL11d <br /> at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> e I <br /> C MAILING ADDRESS Ot APPLICANT PHONE # WITH-AREA CODE <br /> y Z3 <br /> A <br /> N CITY r _/ STATE ZIP E j TYPE of APPLICATION <br /> T `2� CLOSURE, INSTALLATION, etc. <br /> ToT <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I S <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) E /TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) y�Q gT $ �/00d, DD <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H S 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 /> $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-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 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 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 8 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 $ <br /> R REPAIR TANK I.O. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) S <br /> M CONSULTATIONS 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 z6emQD <br /> OFFICE USE ONLY <br /> %0e)D.te%OW)w0%iKe Iwe)0000>:000%00%0000.V>e:<N'N%.'O:<t\O:«e:W',:e\<e..N:<evv:e:e�:L%e:e:^:<•%!e:{?4:CY>:>:vYY:?f?:fiY:Yi:•:J':?:::................ <br /> ry>:'f.<M)K4:OK0%.V <hO:tOO%OO pO: KOe lawO>1000 A00t0%OO A000O%O�XOO A000�%00)0M <br /> �f3EEP5' ��cor>7 " �,tirsT"cciiE T:c�v BY' '1zrI�EI ' Ii� » <br /> g 2[ <br /> 5 sj <br /> 9s...................... ........................ ................. .................................. _ .......... ... <br /> aoexw mwo ree xoow xoe rowsxoe xoe moon zco xooee zw%aos:ero:eu :<!+eo:na:c•>:!e:•�!-:::+.oY:<u•:m•:<!!"..:•%?":?::a:!;e:>;!•:o:ro Y:•%!o••.:ae:ue<o •••• w:000 xos »oo x.wsiwi:oo.w iw:w.eoo»w ww ieaa iooi <br /> >��M ALiDY>WY R�t0Y�l0Y AYJDti;7A'f6�DY68.0DY?A7f'aLJty F:,Y>)L7,"i A}Y«:: .'.%`.5;:,.5 z•Y:K:S,: L'`S �::'.............................,.,.,.....,..•`.S is ^`,:>� �::::�;Gf;mY>DDtDY 9RY FdLaY>mACmDY�A�Y ALY Abt�tAbu>xVl Amf <br /> cu 21 nz� rocV 17/2A/Onl fr PlaP 11 <br />