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JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WCRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> I <br /> T CITY STATE TIP CODE # of TANKS <br /> Y <br /> at SITE <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T <br /> CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 198$ 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> V /s .� S dao <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1 1994 1995 1996 <br /> A (rtu(tiply # by fee for <br /> C each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks 2 x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 1 I ? $ r12 <br /> :J R.ft. +P Y.MOVAI( q0 <br /> C <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-P(ace) TANK I.D. #(s) <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = $ <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E FTEMPORARY CLOSURE FEE = S150.00 each TANK # TANK(s) X 5150.00 = $ <br /> P PLAN CHECK (install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimLn per Facility) = S424.00 mininn S <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 <br /> A = $ <br /> I <br /> R PIPING REPAIR FEE = $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 = S53.00/hr FEE _ $53.OQ/hr FEE = S 53.00/hr <br /> 701AL DUE $ / <br /> OFFICE USE ONLY ~ <br /> wmwm waam wm neom was beoee wm»m}eeeas wm feeeoswm>eeeoo-wm x,wes rem aaee roses seaswoemwm wes»xoswm waaoo-bneweooa zosieaaee leap „;:ese waemb'os»sees�xsicsso:wee woo-wam.wa.waeae rem weaea wes waaae wea weo woom seas was <br /> se`s "" cr° r `o' "c `sc3`r `c° `E `iA�` `c `t °�` �~ `o <br /> .......................... ........................ .................... .... <br /> assawm weem wmnaoasnmbaam nos res weem wmaaasmaass weeasw»waeos wa weo+anm»aeasx»wm wesm ban�ssooi�r'eweaa iiseiaw'e's'wos isesriveu wss• ..•••••••••.•....•,••• ••.••..•.....•••• � <br /> AOYAVAf PAWFRt1L �aF>�Ye6YA�%9i9 �'%�4A1' FAmFAVR7%71$� F rppi FAf/#R4�G%Mi�tf6�%�Ji:6��K AWfoYA'PlA'ffAFDAefALtG%etrLY}w7i iseeasw»xuwooeswes wwwreoo wawa wesxcaiieesisaei+map is.sia <br /> EH 23 032 (REV 1/10/91) ft Pace 11 <br />