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,eQl JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A S�Awv RUG/�/N <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> 1 <br /> T CITY STATE ZIP CCOE # of TANKS <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPEof APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 7988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I �p17 /VV /OV /DU /DD $ �D D <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 9 Tanks1986= 2- 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for G <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> I <br /> T # Tanks Z x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <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/in specti ors) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 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 - 853.00 per hour (8 hours minimum per per Facility) = S424.00 mini mS <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) # TANK(s) X 5159.00 = S <br /> A <br /> 1 <br /> R PIPING REPAIR FEE = S53.00 per hour (3 hour mini mm per facility = $159.00) S <br /> N CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL OU s <br /> 0 � 0 <br /> OFFICE USE ONLY 14 <br /> 6 �04 <br /> kit t <br /> 5 <br /> EH 23 032 IREV 1/10/91) ft Pate 11 <br />