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Sh.. JOADUIN 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 /> I <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 TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> I S <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) S170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply V y—fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 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 5159.00 = S <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 = $ <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) = S424.00 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 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = S159.00) 5 <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = S53.00/hr 5 <br /> S <br /> C CONSULTATION FEE = S53.00/hr SAMPLING INSPECTION FEE = S53.00/hr S <br /> TOTAL DUE S <br /> .........................__._.................._...._.._..._._......................................................................_.........................._..............................................._..........._.._.............._._.._..................._..._....._..._._.._........._...... <br /> SWEEP$ # �CbMPUI�R #� L0� CODEC t}IS1 CODE i AMOUNT` RCVO �H�01( #/CASFI RE "EIV�b $V OATE�REdEIVEY) a <br /> ;: <br /> y S a <br /> :::::..:::.:__-_..:.:._._...._.._.. _ --._.........._......_.._._...-......_..... - - --- - — -- <br /> ................. <br /> ......................................... <br /> ...........* <br /> _..._..__—_ _.....-..._._. _��.._.._..._:._.__.�.�..:�.,�... .....__sem..._ <br /> ..... <br /> EH 23 032 (REV 4/8/91) ft <br /> a <br /> C/3 = <br /> G e Zi7Le <br /> 9 <br />