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AllbOACUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGRCUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />TOTAL <br />A <br />C 1986 1987 1988 1989 1990 <br />T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />I S <br />V <br />TANK FEE = 550.00/TANK (prior to January 1,1491) 5170/TANK (after January 1, 1991) <br />F # Tanks = 1986 1987 1983 1989 1990 1991 1992 1993 1994 1995 1996 <br />A (mutcipty by fee for <br />C each year applicable) S <br />L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br />I <br />T 9 Tanks x 556.00 1986 through 1990 1991 through 1996 <br />Y (enter amount and year) <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />C <br />S <br />L <br />6�19C <br />9 TANK(s) X 5159.00 = <br />IFACILITY <br />I <br />ADDRESS <br />SITE PHONE 9 with AREA CODE <br />T <br />Y <br />CITY <br />STATE <br />ZIP COE j <br />�L 6 <br /># of TANKS f <br />at SITE A <br />I <br />A <br />APPLICANT/BILLING NAME / <br />APPLICANT CONTACT NAME <br />L <br />I <br />C <br />A <br />MAILING AODRES�14� �J <br />APPLICANT PHONE X WITH AREA �E <br />N <br />CdTY 1 STATE ZIP CODE TYPE of APPLICATION <br />CLOSURE, INSTALLATION, etc w';/ <br />TOTAL <br />A <br />C 1986 1987 1988 1989 1990 <br />T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br />I S <br />V <br />TANK FEE = 550.00/TANK (prior to January 1,1491) 5170/TANK (after January 1, 1991) <br />F # Tanks = 1986 1987 1983 1989 1990 1991 1992 1993 1994 1995 1996 <br />A (mutcipty by fee for <br />C each year applicable) S <br />L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br />I <br />T 9 Tanks x 556.00 1986 through 1990 1991 through 1996 <br />Y (enter amount and year) <br />S <br />P PLAN CHECK (Install. Plan Review b Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = S424.00 minimum 5 <br />R <br />E <br />PSMANE4TRE (Removat or Authorized Closure -in -Place) <br />TANK I.D. ;*(s) <br />C <br />S <br />I <br />L <br />CLOSURE FEE 553.00 pe�rYhcwr (3 ho rs minimum per <br />9 TANK(s) X 5159.00 = <br />S <br />0 <br />S <br />U <br />TEMPCRARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. X(s) <br />R <br />ETEMPCRARY <br />CLOSURE FEE = 5150.00 each TANK 0 TANK(s) X 5150.00 = <br />S <br />P PLAN CHECK (Install. Plan Review b Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = S424.00 minimum 5 <br />R <br />E <br />. REPAIR FEE (workptan review & construction inspections) TANK I.O. X(s) <br />P <br />A <br />TANK REPAIR FEE = S53.00 per hour (3 hours minimun/TANK) 9 TANK(s) X $159.00 = <br />S <br />I <br />PIPING REPAIR FEE _ 53.00 per hour (3 hour minimum per facility = $159.00) <br />M TRANSFER FEE = $20.00 <br />S <br />C CCNSULTATICN FEE = S53.00/hr <br />OFFICE USE ONLY <br />UNAUTHORIZED RELEASEE EVALUATION = 553.00/hr <br />SAMPLING INSPECTION FEE = 553.00/hr <br />d <br />IS <br />TOTAL DUE I ' q <br />EH 23 032 cREV 418/911 ft Pace 11 <br />