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"•' JOAOUIN COUNTY PUBLIC HEALTH SERVICES j - <br /> ENVIRONMENTAL HEALTH DIVISION <br /> d UNDEA61rCUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A ` A� <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> - <br /> T CITY STATE ZIP CCOE # of TANKS <br /> Y I I at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> 7 <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHCNE S WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE 21P CODE i7PE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> O AL I <br /> A i u citn <br /> C 1986 1987 1 1988 1 1989 1990 �7Qd <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 / f <br /> 1 jO0 <br /> v 9 (.� S 7U <br /> 7 <br /> -e TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANX (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # y fee for <br /> I each year applicable) ZOO Q(� S <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H s S Cade, Section 25287 <br /> I <br /> T "�ter <br /> z556.00 1986 through 1990 1991 through 1996 <br /> Y and year) <br /> ZZ 5 j <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK($) X 5159.00 = S <br /> 0 <br /> S <br /> U TE14PCRARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 5150.00 each TANK # TANK(s) X $150.00 = $ <br /> P PLAN CHECK (Install. Plan Review S Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) = $424.00 minimum S <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 /> 1 <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION - $53.00 per hour (3 hour mini mm per facility = 5159.00) S <br /> N CCNSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE - $53.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S 3 <br /> OFFICE USE ONLY <br /> nal <br /> `$�E�i�?� �LCMP"3'Te "R"OC CCO�'�'•�IS7CCDE' A)dCUNT"RCVD CnEC/ '�/'CxASA�" C`iD BY 'I��'�'Cc i�'IE��'v�dt�`('�s"�`y <br /> a <br /> a 5 <br /> r«»tx. ...t«»....... ............ .............. a <br /> asrrsawrmr:wswwasavxsx,xsiusx:�;xx:.;�._.ss=:xsxx:»M:xt�s.�':�':.m::tasa„.„�sse„trzs,:a.�ass�ra.�vrear.rwsewa's�aarrroao.r,.xr <br /> ew 71 n12 l>aw fP AA/9nt Fr Pnoe 11 <br /> D ISc. to <br />