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jAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) ,3 <br />L <br />A <br />N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum Is 2(( <br />R <br />FACILITYITE NAME <br />FACILITY CONTACT NAME <br />F <br />Aur/c <br />J�ha1C00n4 <br />CO <br />rl�/do oh <br />A <br />0 <br />c ir­ <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections <br />TANK I.D. #(s) <br />I <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />L <br />1M t <br />1987 <br />I <br />T <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />FEE = S 53.00/hr <br />G J <br />C _ <br />96 <br />at SITE < <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />$ <br />P <br />L <br />E <br />TANK FEE = 550.00/TANK <br />IMAILING <br />C <br />ADDRESS PAYMENT, <br />APPLICANT PHONE # WITH•AREA CODE <br />January <br />1, 1991) <br />F <br />A <br />N <br />CITY <br />t� <br />E�E TYPE of APPLICATION <br />T <br />P, <br />;7 CLOSURE, INSTALLATION, etc. <br />P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) ,3 <br />L <br />A <br />N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum Is 2(( <br />R <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />PUBLIC i ' t '.'Ut\J rY <br />HEA <br />C <br />L <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br />TOTAL <br />A <br />0 <br />c ir­ <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections <br />TANK I.D. #(s) <br />R <br />E <br />C <br /># TANK(s) X $150.00 = <br />MWILNAL HE Ai. <br />i i Di' )g�� <br />1987 <br />1988 <br />1989 1990 <br />T <br />ANNUAL FACILITY FEE (Prior to <br />January 1, 1991) = $100.00 <br />FEE = S 53.00/hr <br />TOTAL DUE <br />1 <br />$ <br />V <br />E <br />TANK FEE = 550.00/TANK <br />(prior to January 1,1991) <br />5170/TANK <br />(after <br />January <br />1, 1991) <br />F <br /># Tanks = <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 c <br />A <br />(multiply # by fee for <br />C <br />each year applicable) <br />S <br />I <br />L <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 <br />S Code, <br />Section 25287 <br />I <br />T <br /># Tanks x $56.00 <br />1986 through 1990 <br />1991 <br />through <br />1996 <br />Y <br />(enter amount and year) <br />P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) ,3 <br />L <br />A <br />N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum Is 2(( <br />R <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />C <br />L <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X $159.00 = <br />S <br />0 <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br /># TANK(s) X $150.00 = <br />$ <br />P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) ,3 <br />L <br />A <br />N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum Is 2(( <br />R <br />REPAIR <br />TANK I.D. #(s) <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X $159.00 = <br />S <br />A <br />I <br />R <br />PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) <br />S <br />M <br />CONSULTATIONS <br />UNAUTHORIZED RELEASE EVALUATION <br />SAMPLING INSPECTION <br />1 <br />S <br />C <br />FEE = 553.00/hr <br />FEE = 553.00/hr <br />FEE = S 53.00/hr <br />TOTAL DUE <br />5 <br />OFFICE USE ONLY K H P'—U T v <br />....................................................................... <br />MVO MVO%OCVO Mb MVVVO MVP MOOJO MVO MVO MVYq %0O:O0.Y %.V )<(\O:«O:i4ih%!O rH <br />s I I <br />g!........... K- ...........o.. ......... <br />MVP MM MCVM MW MOVVP MVO A=MVO"ON MCO MW MVO %NVO:OX'W", %!O' <br />A0Y Rl� A�l%�DIY �7WY �DLii AZYf6 AW viii ACAb�f'.tN19AY«#`« ik7« AIX «Si.: •«' <br />cu 7: nz7 f0rV 17/7f/On1 ft <br />O:Pi:•' ri0 i:!K <br />»•C •\ »Y �\ r.. IDLY <br />X110111)7 RC W' C}(EC;C• WCASNRWW- " TAE��12�C `I E TV1Y x » <br />g <br />550 <br />r <br />cx��yZy �-o� y -Z3 -I....... .......... <br />................................................................................... <br />:<!rr0 >�:y:Ci:wii%S. i:M.i �•.: J:ti•iii:i:^ii}�:i:!Ji :!!n .:!r!w e.. !O �N!O:<!O A." ro!GttOP%OO MVO AoeOP%a0%OPaP%W %ooPP MM AOOPP APS%M MCOaP KVP �oO► <br />...::Y::/.fib:".'.'.%Y^.�>:.^•.�<;:;;;�>::`:i::`::::�::i:4: ?'::' `:6:::.,.,...„si )':Si iR:L.':7Cd �LDY SDTDD1�:m%AD3Y6 Algi%�f6>zJAiA�LY AD1i �5Y �DLL'eli>atX �D7i <br />Pnce `1 <br />