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+ -W JCACUVI COUNTY PUBLIC HEALTH S£AVICES <br /> ENVIRONNEVTAL HEALTH DIVISION <br /> i URh-A,6CUW0 STCRACE TANK PROGRAM FIE LCRKSHE£T 'ar'� <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> f � <br /> 1 FACILITY ADORESS <br /> SITE PHONE ! with AREA CODE <br /> - <br /> T CITY L/, T TE ZIP CODE R of tARKS <br /> Y ��C�,�/ at SITE / <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT RAME <br /> Lp <br /> I MAILING ADDRESS f / APPLICANT PHCNE S WITH AREA CODE <br /> A / 51 1 3 ms`s // '.Yid`/cwC <br /> N CITY '//� STATE ZIP COD'e TYPE of APPLICATICN <br /> T /GT ��.� 1 �J ��. CLOSURE, tNSTALLAi4 etc. c •- <br /> } <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> I ANNUAL FACILITY FEE (Prior to January 1, 1991) + $100.00 <br /> 1 5 <br /> v <br /> E TANK FEE + S50.00/TANK (prior to January 1,1991) 5170/TANK (after laruary, 1, 1991) <br /> F Tanks = 1986 1987 198E 1989 11990 1991 1992 1993 1996 1995 1996 <br /> A (aultiply S—by fee for <br /> C each year applicable S <br /> I <br /> L STATE SL•RCRARCE + $56.00 each TANK (Due every S years) See California N t S Code, Section 25237 <br /> 1 <br /> T : Tarks z S56.CO 1991 throvo 1996 <br /> Y (enter xnonnt and year <br /> S <br /> PERMANENT CLOSURE (Removal or Aut rfFef C3oj4MjIn-P1 see) I TANK 1.0. JIM <br /> C <br /> L CLOSURE PEI + $53.00 per hour (3 hours minlncse per TANK) B TANK(s)�— X $159.00 a <br /> D8WRONMEN 17T HEAL]H <br /> s <br /> U TEMPORARY CLOSURE (A one-time perm , Peet Ions) TANK I.D. '(S) <br /> R <br /> ff iE.vP(RARY CLOSURE FEE a $150.00 each TANK 0 TARK(s) _— X $150.00 = S <br /> IP PLAN CHECK (Install. Plan Review L Construction Inspections) TARK I.D. ?(s) <br /> IL <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour IS hours mini" per Facility) + S626.00 mini cue 5 <br /> R REPAIR FEE (workplan review L construction Inspections) TANK I.D. 0(s) <br /> P TANK REPAIR F-es_ a S53.0 per hour 0 hours minieu ITANK) 0 TANK(s) _ X $159.00 = S <br /> A <br /> I <br /> t PIPING REPAIR FEE + S53.00 per hour (3 hour mini" per facility + $159.00) S <br /> M CCUSUL TATICRS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> FEE a 553.00/hr FEE = $53.00/hr IEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE CHLY ✓�v" 13 <br /> ------------ <br /> -- _ ---- <br /> a.e_rias I��I�i� - I tCF;.�~i)ISn C�Jea��i 1C��aC'b^ I �neu�s/`�,�i�l neC:Mv��e� I nil�e Re�_M rc�fi <br /> .r�.�wi:r•.i i.r.�.r�.rrarnwi n+w+w�.+.►.a.. i++:ai+�ai+�++ri �a+i+rr aiw�+�arr rswr�r <br /> 23 932 (RFA 1/10/911 ft Pace 11 �� <br />