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'ft4AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES m� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILIIY SITE NAME FACILITY CONTACT NAME <br /> F ff <br /> r k TIOn AOViC <br /> I FACILITY ADDRESS SITE PHO with EA CODE <br /> I (/n <br /> T CITY STA E ZIP CODE # of TANKS �' <br /> Y Ff G at SITE T(UC <br /> A APPLICANT/BILLING NAME APPLICANT CONTACTNAME <br /> L Fjjer n i eP n' 'u Jc a un <br /> L <br /> C NAILING ADDRESS APPLI T HONE # WITH AREA CODE <br /> A CJ'/0 1" <br /> N CITY S AATE ZIP CODE TYPE of APPLICATION GTION <br /> T >n't �a l CLOSURE, INSTALLATION, etc. L <br /> A TOTAL <br /> C 1986 1987 1 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I S <br /> 4 <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1 1991 1 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) S <br /> 1 <br /> L STATE SURCHARGE - 556.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> I <br /> T # Tanks x S56.D0 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) <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimus per TANK) # TANK(s)�< x 2159.00 = S O <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 5150.00 = 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 minim per Facility) - $424.00 minim S <br /> R REPAIR FEE (workplan review t construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE - 553.00 per hour (3 hours minim.MTANK) # TANK(s) _ X 5159.00 5 <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minim.m per facility - $159.00) $ <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = S53.D0/hr $ <br /> I <br /> S <br /> C CONSULTATION FEE = 553.00/hr SAMPLING INSPECTION FEE - 553.00/hr $ <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> r ®ee}pprs L � 'fi S�L � L�iS�`�' A� ��' L��'m'�os'�'� c 'ors ■ <br /> :....[.?Q�..._.. GF.�:Jrrsz.. .....�F.__.._ ....�ZS—.._.... =;�,L..[,.`...-.°°.,�.,=;,3_�.>?�-. i":_ 1.�„>•,,1.� ... ... �,�;�. <br />