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SOAOUIN 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 /> C <br /> I FACILITY ADDRESS SITE PHONE 8 with AREA CODE <br /> L <br /> I <br /> T CITY STATE ZIP CODE 0 of TANKS <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P E / <br /> L <br /> C MAILING ADDRESS APPLICANT PHONE S WITH AREA CODE <br /> A / <br /> N CITY STA E ZIP CODE TYPE of APPLICATION <br /> T �^y CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> 1 ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 $ <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 !]1Pn <br /> 1491 1942 1993 1994 1995 1996A (multiply fee forC each year applicable) S <br /> I <br /> 1 STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H &-S Code, Section 25287 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> am <br /> Y (enter oult 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 /> B TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = S <br /> PPLAN CHECK (Install. Plan Review $ Construction Inspections) TANK B.D. $(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 minimum S <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) f <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $53.00/hr S <br /> S <br /> C CONSULTATION FEE = S53.00/hr SAMPLING INSPECTION FEE = $53.00/hr S <br /> TOTAL DUE S 31 0 ,Qa <br /> OFFICE USE ONLY <br /> PiIr KrAr1VrU <br /> E`er$ E POOt)E.» iis �ciF :rs +ifmlFue ss.. <br /> c <br /> .._.. .ynlcm;xr«?�E.?E?i':•.eie??iEiii?EFi:T.sls ..�.ifiaesfnm <br /> 34:iffEurs:.°is3iiii44W4L'iku"iiiiiulEEli <br /> EH 23 032 (REV 4/8/91) ft <br /> PAYMENT <br /> RECEIVED <br /> {�g <br /> p 1592 f <br /> SAKI JOAQUIN C-0i:��TY <br /> PUBLIC HFAILT`i 4E_a1r <br /> ENVIRONMENTALHEPLI-H � �0 <br />