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WOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OIVISICN <br /> UNOERGRCURO STORAGE TANK PROGRAN • FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> � IT� C� tmes-nW( 9yy ' <br /> WARS <br /> I FACILITY ADDRESS SITE PHONE # wt AREA CODE <br /> 171 o I 4Z bq )o� o - �a - o o <br /> f.�. T CITY �,-,.� STATE ZIP CODE O # of TANKS <br /> at SETE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAM//E11 I' ll <br /> P <br /> SF/ly1 G0 �IC�IA�J C f �1Yl tb7J✓� <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> 0 x709 <br /> iCITY '^ �GS� STATE 2 P CCOE TYPE of APPLICATION 7Y10N)T-O(2.I r\1(� <br /> v C(� 5351 CLOSURE, INSTALLATION, etc. SYS Ff'M'q <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991). = S100.00 <br /> I <br /> V <br /> S <br /> E TANK FEE S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 0 Tanks = .y 1986 1987 1988 1989 1990 1991 1992 1993 1996 1995 1996 <br /> A CmLtiply # by fee for <br /> C each year applrcabl e) S <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> i <br /> T # Tankf �- x S56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK t.0. :(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) 2 TANK(s) X $159.00 a S <br /> 0 -- <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review b inspections TANK 1.0. #(S) <br /> R <br /> TEMPORARY CLOSURE FEE = 2150.00 each TANK ;'TANK(s) % 5150.00 . S <br /> P PUN CHECK (Instalt. Ptan Review 3 Construction Inspectlons) TANK J.D. #(s) <br /> l <br /> z <br /> N <br /> PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) a 5626.00 minimum S <br /> R REPAIR TANK I.D. 1(5) <br /> e <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) tANK(s) X 5159.00 • S <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW S CONSTRUCTION = S53.00 per hour (3 hour min!" per facility = S159.00) <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 153.00/hr FEE 553.00/hr FES = S 53.00/hr -�--. <br /> L- 3 <br /> C TOTAL DUE <br /> OFFICE USE ONLY L✓ <br /> _„._....__..__ — <br /> c•?S CG4P'� '� �L'Gt�CO�E 7'I ST CCD-e AMCUFTF6� Cnc�L' '/CAS'n <br /> a ` <br /> `S ■ <br /> 1•i�liiioa�a=assf:mu.-s�u:.�mliY NT A._.:Y:GS.«..M...........r.'... .. - '� <br />