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JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />FiASITE NAME T <br />IILLITY CONTACT NAME <br />1 FACILITY ADDRESS <br />REPAIR FEE (workplan review & construction inspections) <br />TOTAL <br />SITE PHONE # with AREA CODE <br />` <br />1 1986 1987 1988 <br />ANNUAL FACILITY FEE <br />1989 1990 <br />T CITY ST TTE <br />Y �C-A, �l/ <br />ZIP ?CODE_ <br /># of TANKS <br />PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = $159.00) $ <br />V <br />at SITE <br />A APPLICANT/BILLING NAME <br />P <br />APPLICANT CONTACT NAME <br />P <br />L <br />I <br />MAILINGADDR S <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />Z �" <br />N <br />T <br />CITY STAJE <br />ZIP E TYPE of APPLICATION <br />1989 <br />1990 1991 <br />OSU INSTALLATION, etc. <br />A <br />REPAIR FEE (workplan review & construction inspections) <br />TOTAL <br />C <br />T <br />` <br />1 1986 1987 1988 <br />ANNUAL FACILITY FEE <br />1989 1990 <br />1 <br />(Prior to January 1, 1991) = $100.00 <br />R <br />PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = $159.00) $ <br />V <br />TOTAL DUE <br />$ / 5-� <br />= <br />E <br />TANK FEE = $50.00/TANK (prior to January 1,1991) <br />$170/TANK (after January 1, 1991) <br />F <br /># Tanks = <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />A <br />(multiply # by fee for <br />C <br />each year applicable) <br />1 <br />$ <br />L <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) <br />See California H 8 S Code, Section 25287 <br />I <br />T <br /># Tanks x $56.001986 <br />through 1990 <br />1991 through 1996 <br />T <br />(enter amount and year) <br />S <br />C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) A/ /f" <br />LO CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) 1 _ x $159.00 = S� of $ <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 $150.00 = $ <br />FPPLAN 7CHECKFEE <br />tall. Plan Review & Construction Inspections) TANK I.D. #(s) <br />$53.00 per hour (8 hours minimum per Facility) _ $424.00 minimum $ <br />0-0 <br />R <br />E <br />REPAIR FEE (workplan review & construction inspections) <br />TANK I.D. #(s) <br />P <br />A <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimuVTANK) <br /># TANK(s) X $159.00 = $ <br />1 <br />R <br />PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = $159.00) $ <br />l <br />S <br />MrfEE"= <br />ULTATIONS <br />UNAUTHORIZED RELEASE EVALUATION <br />SAMPLING INSPECTION <br />C <br />$53.00/hr <br />FEE = $53.00/hr <br />FEE = $ 53.00/hr <br />TOTAL DUE <br />$ / 5-� <br />......................................... <br />� azw..lNa Mw.�MaN wN Miioaooi i000 <br />5t�S AIN <br />INS 00 NO NOW <br />XN MO W NO NNN NO NO XNN NN M0 M.00 MN M0 MON 1000 M000 M0 <br />EN 23 032 (REV 1/10/911 ft <br />$ <br />M0 M00 MON MN MON M0 )00000 M0 M0 )DOM <br />XXXW*qNXXAVNFXXXN11W <br />. . .............................. 1.......................... <br />)00100000 M010000. 100. MN MOM 1100INN. lN0 )DON. `000 MN <br />W NXW xx MON LMC No NON XX iRX NX r'x xa <br />Paae 11 <br />a <br />........................................... <br />000 MN 1000N MN MON 10.0 )000 )00000 M0 MM <br />