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'3PM JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIROMWENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM -FEE WORKSHEET <br /> 5 FkLITY , TE NAME I F ILT1/13 FADDRESS s "� e� SSI � ONE �ith AREA CODE <br /> A C <br /> P T��f ., e� �J9TE ZIP CODE atoSITENKS Z <br /> FC (}1 <br /> P APPLiCAN7 BILLING NAME APPLICAN ON CT NAME <br /> E/t/t a Twp 4 <br /> C MAILING ADORES PLI NTPHON_# WIT AREA CODE <br /> N JZ l <br /> T T a o ST TE P Cpp TYPE at APPLICATION k7'0 <br /> C Cf� 'S'Zj � (Closure, Installation, etc.) LZ'0W70va <br /> TOTAL <br /> A TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> C <br /> T # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> I (multipLy ii:6y—fee for <br /> V each year applicable) XXX% xxxx xxxx XXxX Xx%X S <br /> E <br /> TANK PENALTY FEES ASSESSED xxxx xxxx xxxx %XXX xxxx $ <br /> S <br /> T STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> E # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter aaaunt and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) TANK I.O. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours mini mum # TANK(s)�` X 5734.00 = S �,UV <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> El TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> IIREPAIR FEE (Workplan Review & Construction Inspections) <br /> TANK 1.D. #(s) <br /> E <br /> A TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 mini muga S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br /> N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S / (� <br /> TOTAL DUE <br /> FOR:::9_F,FI,f_U,SE.,QM,IT S_ 1_ _ _ <br /> -.__ v� ;. _a-r.:• <br /> sof � -J-LaG COOJ-03`x-CW9-E7WNTis% rvE1S HEZK�lJZFs � �ftEC rOE15 7=aft�E RELEIv¢D <br /> aps OMDUIT; # <br /> ........ <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />