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JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRCUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT-NAME <br /> F � <br /> A �- 5 N <br /> C - <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> T CITY STATE ZIP CODE # of TANKS <br /> Yi `7• at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P �- <br /> L <br /> I 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) = $100.00 <br /> I <br /> V WW <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991)UG-j471 5170/TANK (after January 1, 1991) <br /> F # Tanks = J— 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) )( 1 �( S 7 oa <br /> I 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_L_ x $56.00 1986 through 1990U6-jrZtj u&-T#�1991 through 1996 ( �Z <br /> Y (enter amount and year) I <br /> QCFht PT (4 &)t51 S c 00 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C o <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = 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 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) 2= <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 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) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> wasxaaz�a:ao.xeooszeozeeeowooxoaaoewozoozamesxaeweoaexeexeaeexe.xaa�ee000xo.zeaozeaxeeesxaa xe►aux,oxacoxeswaemaxesxoeeo»ao�ee.wowexasxoee.meszaooszes�oeaxowexes�omeosxesxeeao xaax0000xasxooxoeoo�oesze. <br /> G'�'+� '- lio3 �q. �],,� <br /> g.�.4rS..0 .... ........................ .................... 5. � ........... oe21 ................. IZ�Z($��iG "� ZII�Cj� <br /> .. ............... ..........................................9n <br /> aawxo►xeeesxes xwaeeeea�zoo�oa+xeeo.�eooxeaes�easxeee►xaxa.s xoaxeewxoexoeesxme�aexaasxms�aeeasmae,aaee.xa.xaaesxaxesxeewxa' xooe.xesxo.xeeasxeaxee.sxaexeeesxo.xo.o.�eeaeae xe.o.xe.xw <br /> r�crs,��matm<teamc�osaafem<�vsa�cs�cac �rot�raaraaato� xz�saaumm �vz am�a� a�ac�c �cuaraa�cte�t�a <br /> EH 23 032 (REV 1/10/91) ft Pace 11 <br />