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JOAQUIN•COUNTY PUBLIC HEALTH SERVICES <br />w p <br />ENVIRONMENTAL HEALTH DIVISION ,� :�ib5 ' i► <br />UNDERGRCUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />AGILITY SITE NAME FACILITY CONTACT NAME <br />�r� _' 1 i 4 --L t� <br />C <br />ndcI UN 19, 1991 <br />I FACILITY ADDRESS <br />L9( <br />h6 SITE PHONE # with AREA CODE r <br />r ,;Ir���.A! HEALTH <br />ES <br />T CITY STATE ZIP CODE # of TANKS <br />Y zl Q at SITE <br />A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br />" s- 1 r� �- <br />L �G <br />I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />C <br />a u1, o <br />N CITY STATE ZIP CODE TYPE of APPLICATION <br />T CLOSURE, INSTALLATION, etc.t� t <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 2 <br />E YANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br />F # Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br />A (multiply # by fee for <br />C each year applicable) ,; 2 / p A v <br />I avv o� <br />L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br />I <br />T # Tanksx $56.00 1986 through 1990 1991 through 1996- A4 <br />Y (enter t and year) <br />C PERMANENT CLOSURE (Removal or Authorized Ctosure-fn-Place) TANK I.D. #(s). <br />L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) <br />0 X 2159.00 = g <br />S <br />U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.O. #(s) <br />R <br />E TEMPORARY CLOSURE FEE = S150.00 each TANK # TANK(s) X 2150.00 = g <br />PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br />1 <br />P PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum <br />R REPAIR FEE (workptan review & construction inspections) TANK I.D. #(s) <br />E <br />P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK)# TANK(s) X 2159.00 = g <br />A <br />t <br />R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = $159.00) <br />M COiISULTAtCONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br />I <br />S <br />C FEE _ $53.00/hr FEE _ $53.00/hr <br />FEE = S 53.00/hr <br />TOTAL DUE <br />OFFICE USE ONLY <br />0\ <br />