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SAW JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A <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 /> P <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE I TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100.00 1966 1987 1988 1989 1990 <br /> 1 S <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1495 1996 <br /> A (multiply 7-5y--fee for <br /> C each year applicable) <br /> $ <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = $ <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D_ #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum S <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # 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) S <br /> M TRANSFER FEE 520.00 UNAUTHORIZED RELEASE EVALUATION = S53.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = S53.00/hr SAMPLING INSPECTION FEE = 553.00/hr S <br /> A1C 1f� �1 ( TOTAL DUE S <br /> .............Y.A.�aAc?!.•-L Mess�Hl. mi*RTlT__ ._ srrs;.rr.�rssmr.ss:...::--r.->_mrmnn::r.-rr.:u.—asz:u-;rugim�rt��ums:. ...� <br /> -. :.::.. .:.......-3 ..._.__...____.�_._ __.�.:....._..—..� __ .. ....... ..... -,. .......x.>...:.. <br /> ..—sw ``; jE� uT F`�T' •c Eprs�-er;i3�aAtsuur c ��-�-ERR ���� —`>1 -9;: ry ry ri <br /> mssaromnrmtmsv a�:em••vn:u•xmnr.. rsx•::xs::::an:ae .r-:.:,^x;: s.,.^^^:r.•r.:.^^r.::a::rn»m:r.:rr•^:••r .ra:m:rrr.::m.... saa.. <br /> _........_..__._T...a_'T_:c?.=......_........._.........__.._..........!?arm!f?r�?€?yttr!....................».....»...............................................................»....,........,...........»..............»............E...-............................................................!iT?s......,........................... <br /> .....' <br /> ......-.��....._......................._......_.._...__.........._._.__.... _..._._.__..__.................... ........:»:::_................................................................_..........................................__...._....._.........._...... <br /> •...........•-.•. >.. ud ss;-•..... sssssysssssss-s'.aas,,,...,•,•-••••••••suuuwu.uuuss.u-ssssss:uu.unsuuwu:u:u •,••-••-•••-••,•••,,•••••;i <br /> EH 23 032 (Revised 4/8/91) Page 11 <br />