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*SAN J0A(XJIN COUNTY PUBLIC HEALTH SERVICES 16 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACI�E r <br /> F GC <br /> C N E <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> T CITY STATEZIP CODE # of TANKS <br /> Y i 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 UCS i TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I I p>!1 <br /> V $ ao <br /> W <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) x P-1- 1 i) g 7 0 o a <br /> I I <br /> L STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks,J_ x $56.00 1986 through 1990()&j�� �.�r r 1991 through 1996 UG-j#( UCG �2 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) UT ! <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 = $ <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> P ' <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 minimum Ts <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 = $ <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE _ $53.00/hr FEE _ $53.00/hr FEE _ $ 53.00/hr <br /> TOTAL DUE $ 00 <br /> OFFICE USE ONLY <br /> .................................................................................................... ........................................................................................................ <br /> ..................................... <br /> xoaxosx000exesxeeoexaowoxaxoo-xoaw000azoaxeoo>xeo-x0000-xosxoeeoxeeGeeexooerwoexeooexeo-xeeesxoexesxeeosxaaxoeeaxaoxooeexaexoeooxoo-woexeees»eawooaexeexeeoaxosxasx000axeawoeeexeo-zeooaxaxeeooxoexeoxe000xaoxe> <br /> RM <br /> 4A � `� <br /> �� f 2 $ 55� i�o3a,z►c3- <br /> ............... <br /> EH 23 032 fREV 1/10/91) ft Paae 11 <br />