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t ' NIy d(oc fa.hl . <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> T <br /> ENVIRONMENTAL HEALTH DIVISION T <br /> UNDERGROUND STORAGE TANK PR - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> 1 <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P ( <br /> L •�J <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C Z <br /> A Uj <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T TCsn Z CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C [11!9_86 1487 1988 1 9489 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I S <br /> IV <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks 1. 1486 1987 1 1988 1 1989 144Q 1941 1992 1493 1994 1995 1996 <br /> A (muttipty # by fee for <br /> C each year appt icabte) 11M !®U i gU (XJ S <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See Catifornia H & S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y Oster amount and year) <br /> Il 2 0(2 $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A am-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> ETEM Y CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Instatt. Plan Review $ Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> H PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facility) = $424.00 minimum S <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hairs minimuWTANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION a 553.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S53.00/hr SAMPLING INSPECTION FEE _ $53.00/hr S <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> uw7iwsou»iweo:ac:.ae�.�;.,m.�»»M» axa.ismer»�»wow»ii»�mw»m»»aro».u»»x»:.:»a»m»»w.►aw.i�a:H.:xe:»��.caw►�+«.xa.�a.:».�ow�me. iano»z»ain»�em:ux»»;,maaom»�e:uea» x» <br /> aeacct�S � SYa` /4 s <br /> NJD . <br /> EH 23 032 (REV 4/8/911 ft Pace 11 <br />