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S • <br />JOAQUIN COUNTY PUBLIC HEALTH SER' 'S <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />7 <br />/`�' # <br />$170/TANK (After January 1, 1991) <br />T <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />1986 <br />x) l A-) , <br />1988 <br />& <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />A <br />MAA-) T -EC A <br />CA <br />q -Y336 <br />at SITE <br />P <br />PPLICALING NAM <br />APPLICANT CONTACT NAME <br />2/ft Y/�0.2 TOS <br />L <br />XXXX <br />I <br />C <br />MAILING ADDRESS <br />AP LEANT PHONE # WITH AREA CODE <br />-/D/mss <br />A <br />I I <br />� <br />NSTATE <br />ZIP CODE TYPE of APPLICATION <br />T <br />CITY <br />(Closure, Installation, etc.) <br />A <br />TANK FEE = S50.00/TANK <br />(Prior <br />to January 1,1991) <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I <br />$170/TANK (After January 1, 1991) <br />C <br />T <br /># Tanks = � <br />= $234.00 minimum $ <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 1992 1993 1994 11995 11996 <br />I <br />(multiply iirFy--fee for <br />$ <br />V <br />each year applicable) <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />I I <br />EI <br />TANK PENALTY FEES ASSESSED <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />XXXX <br />I $ <br />S <br />I <br />STATE SURCHARGE = $56.00 <br />each TANK <br />(Due <br />every 5 <br />years) <br />See <br />California H & S Code, Section 25287 <br />T <br />E <br /># Tanks x $56.00 <br />1986 <br />through <br />1990 <br />1991 through 1996 <br />(Enter amount and year) <br />$ <br />C PERMANENT CLOSURE (Removal or Authorized Closure - in -Place) I TANK I.D. #(s) <br />L, <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 5 7�f�-- <br />S <br />U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />R$ <br />E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A g <br />N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I <br /># TANK(s) X 5234.00 = S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum $ <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum S <br />MTRANSFER FEE = $20.00 <br />I <br />S <br />ClCONSULTATION FEE = S78.00/hr <br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I I S <br />SAMPLING INSPECTION FEE = S78.00/hr S <br />TOTAL DUE 1 % 0 Z . <br />EH 23 046 (Revised 7/10/96) Page 11 <br />