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JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION 9 <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />C <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />A <br />C <br />L <br />0 <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X $159.00 = <br />$ <br />S <br />I <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />L <br />I <br />O ks OEA <br />T <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 51.00.00 <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br />s <br />I <br />T <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />Y <br />% <br />A <br />N <br />at SITE <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />F <br /># Tanks = <br />P <br />L <br />D�_^ <br />A44ij oh �BA sJ <br />A <br />(multiply # by fee for <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br />I <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />$ <br />C <br />each year applicable) <br />I <br />$ <br />N <br />CITY <br />STATE ZIP CODE <br />TYPE of APPLICATION <br />TLA+�t-012X33 <br />L <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) <br />CLOSURE, INSTALLATION, etc. <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) <br />TOTAL <br />A <br />L <br />0 <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X $159.00 = <br />$ <br />S <br />C <br />U <br />R <br />1986 1987 1988 1989 1990 <br />T <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = 51.00.00 <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br />s <br />I <br />V <br />P <br />L <br />PLAN CHECK (Install. Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) <br />E <br />TANK FEE = $50.00/TANK (prior to January 1,1991) <br />$170/TANK <br />(after January 1, 1991) <br />F <br /># Tanks = <br />1986 1987 1988 1989 <br />1990 1991 <br />1992 19931994 1995 1996 <br />A <br />(multiply # by fee for <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) 3 X s159.00 = <br />$ <br />I <br />$ <br />C <br />each year applicable) <br />I <br />$ <br />M <br />I <br />S <br />CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br />L <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) <br />See California H & S Code, Section 25287 <br />I <br />T <br />FEE = S 53.0 /hr <br />T <br /># Tanks x $56.00 1986 through 1990 <br />1991 through 1996 <br />Y <br />(enter amount and year) <br />$ <br />C <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) <br />TANK Y.D. #(s) <br />L <br />0 <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X $159.00 = <br />$ <br />S <br />U <br />R <br />TEMPORARY CLOSURE (A one-time permit, for review/inspections) <br />TANK I.D. #(s) <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br /># TANK(s) X $150.00 = <br />$ <br />P <br />L <br />PLAN CHECK (Install. Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />A <br />N <br />PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) <br />= $424.00 minimum <br />Fs <br />R <br />E <br />REPAIR FEE (workplan review & construction inspections) <br />TANK I.D. #(s) Z <br />P <br />A <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) 3 X s159.00 = <br />$ <br />I <br />R <br />PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) <br />$ <br />M <br />I <br />S <br />CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br />C <br />FEE = $53.00/hr <br />FEE = $53.00/hr <br />T <br />FEE = S 53.0 /hr <br />OFFICE USE ONLY <br />TOTAL DUE <br />s q717 <br />EH 23 032 (REV 1/10/91) ft Paae 11 <br />