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9 AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES If <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />P <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />F <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X $159.00 = <br />A <br />0 <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections <br />TANK I.D. #(s) <br />C <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br />A <br />I <br />FAC IITY ADDRESS <br />SITE PHONE # with AREA CODE <br />L <br />I <br />T <br />CITY <br />STATE <br />ZIP CODE <br /># of TANKS <br />Y <br />1986 <br />1987 <br />1988 1989 1990 <br />at SITE <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />P <br />L <br />$ <br />I <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH 4REA CODE <br />C <br />V <br />A <br />H <br />CITY <br />STATE ZIP CODE <br />TYPE of APPLICATION <br />T <br />(after <br />January 1, 1991) <br />CLOSURE, INSTALLATION, etc. <br />P <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />C <br />L <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X $159.00 = <br />TOTAL <br />0 <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br />A <br />$ <br />C <br />C <br />FEE = $53.00/hr <br />FEE = $53.00/hr <br />1986 <br />1987 <br />1988 1989 1990 <br />T <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = <br />$100.00 <br />I <br />$ <br />V <br />E <br />TANK FEE = $50.00/TANK <br />(prior to January 1,1991) <br />$170/TANK <br />(after <br />January 1, 1991) <br />F <br />0 Tanks = <br />1986 <br />1987 <br />1 1988 <br />1 1989 <br />1990 1 1991 <br />1 1992 <br />1993 <br />1 1994 <br />1 1995 <br />1 1996 <br />A <br />C <br />(multiply # by fee for <br />each year applicable) <br />5 � 0 <br />$ � p0' <br />I <br />L <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 <br />years) <br />See California H & <br />S Code, <br />Section 25287 <br />I <br />T <br /># Tanks 3 x $56.00 <br />1986 through <br />1990 <br />1991 <br />through <br />1996 <br />Y <br />(enter amount and year) <br />' <br />S <br />P <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />C <br />L <br />CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) <br /># TANK(s) X $159.00 = <br />S 3 <br />0 <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br /># TANK(s) X 5150.00 = <br />$ <br />P <br />PLAN CHECK (Install. Plan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X $159.00 = <br />L <br />A <br />A <br />N <br />`� <br />PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum $ `t 2_� <br />S <br />R <br />REPAIR <br />TANK I.D. #(s) <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br /># TANK(s) X $159.00 = <br />$ <br />A <br />1 <br />R <br />PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = S159.00) <br />S <br />M <br />CONSULTATIONS <br />UNAUTHORIZED RELEASE EVALUATION <br />SAMPLING INSPECTION <br />I <br />S <br />C <br />FEE = $53.00/hr <br />FEE = $53.00/hr <br />FEE = $ 53.00/hr <br />TOTAL DUE <br />$ I <br />OFFICE USE ONLY <br />.............................. <br />6..�... .. ..... ...................... ................. <br />ps xes xeow wes xmwsxo�:ws %ooao �000xa000xooXexs: <br />IOii f OLS dpi �d% Rb16 � mALY �diG k13ts T:'7f >Y.7v <br />cu �i nti focV 19/;'A/®n1 ft <br />$ <br />ore <br />.'.................95 <br />�.w �..e.s �oo►Aa► <br />ADi:D2610�.1effi AWS <br />