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'AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> _ ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE MMIE FACILITY CONTACT NAME <br /> F <br /> A <br /> C -Q L <br /> I FACILITY ADDRESS SITE PHONE 9 with AREA CODE <br /> L <br /> 1 S. �'aa�Zar <br /> T CITY I St zip CODE d of TANKS <br /> T S at SITE <br /> A APPLICANT/BILLING RAMS APPLICANT CONTACT NAME <br /> P 5 P � <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1 1988 1 1989 1990 <br /> TSANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> 1 <br /> V <br /> E TANK FEE = S50.DO/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 9 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1 1995 1996 <br /> A (multiply C byby fee for <br /> C each year applicable) S <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H b S Code, Section 25287 <br /> 1 <br /> T 9 Tanks x $56.00 1986 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(s) <br /> C <br /> L CLOSURE FEE = S53.DO per hour (3 hours minimum per TANK) S TANK(s)_ X 5159.00 = 5 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A ore-time permit, for review/inspections) TANK I.D. S(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK S TANK(s) _ X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review S Construction Inspection,) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE 553.00 per hour (8 hours minimum per Facility) • $424.00 minimus 5 <br /> R REPAIR FEE (workplan review 6 construction inspections) TANK I.D. @(s) <br /> E <br /> P TANK REPAIR FEE = 253.00 per hour (3 hours minimm/TANK) I TANK(s) _ X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = S53.00 per hour (3 hour minimum per facility = $159.00) 5 <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S53.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE • 553.00/hr SAMPLING INSPECTION FEE = 553.00/hr 5 <br /> TOTAL DUE 5 SCC' <br /> OFFICE USE ONLY <br /> "S/w,cc�`5 'm /�/ +t�1i� <br /> JJ <br /> a...�...�"..r� .. r r <br /> ark=MMr�=wsiM�=�i1��iwr=iifr,Yi�i��wa=1�=�vrsr=r�rr=w�r=r asr fwMea�'.��rw�� =w�rwTMYs <br /> IlmOmi!•M11fM»:llr YOtfamllltlYYtIiOIIYYMiy'^sOarP1=Y)W liaYlNMlifali mamsarr�oaamrrxwruur�s/1mAt•lmf AalafYfia�fYAlfArlWm[ai��MflYO <br /> EH 23 032 (REV 4/8/91) ft Daae 11 <br />