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0590 01L AeJV1"- 5,rr1,,w14.4 Z 4i4erE Afp .N JOAOUIN COUNTY PUBLIC HEALTH SERVICES ��F �� `. ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET -?fG �a S C FACILITY SITE NAME FACILITY CONTACT NAME F CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = C A U R TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) I FACILITY ADDRESS SITE PHONE # with AREA CODE L I T Y CITY STATE ZIP CODE # of TANKS C at SITE A APPLICANT/BILLING NAME APPLICANT CONTACT NAME P 1990 P ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 L I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE C A N CITY STATE ZIP CODE TYPE of APPLICATION T $170/TANK (after January 1, 1991) CLOSURE, INSTALLATION, etc. C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) L 0 CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = TOTAL A FEE = $53.00/hr U R TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = $ C 1986 1987 1988 1989 1990 T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 I V E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) F # Tanks = 1986 1987 1988 1989 1990 1992 1993 1994 1995 1996 A C I (multiply # by fee for each year applicable)p,b ADD [1991 /� L I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) _ See California H & S Code, Section 25287 T # Tanks Z x $56.00 1986 through 1990 1991 through 1996 Y (enter amount and year) C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) L 0 CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = $ S FEE = $53.00/hr U R TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = $ P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) L TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = $ I FEE = $53.00/hr A PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = $159.00) $ N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 minimum $ R E REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) P A TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = $ I FEE = $53.00/hr R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = $159.00) $ M I S CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION C FEE = $53.00/hr FEE = $53.00/hr FEE = S 53.00/hr TOTAL DUE S OFFICE USE ONLY ................................................ ww wro wove wro »aro ww w0000 ww ww waw �sox�sSc�S"'�LC1P�1 f t�i� g..........................1............ wro woe weeoe was woow aro waw wro ww a,� s7s std sr�c gess rau sera aes aau EH 23 032 (REV 1/10/91) ft .......................................................... . ww wowo ww waw ww weeee wro waw wro ww w000e wro r Pace 11 WX ......................... we wro wro waro wro wro waro wro wee www wro wro �ras,e� a�nc>taamc mac aa�