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01 <br />u <br />SAny.,ACUIN COUNTY PUBLIC HEALTH SERVICES ..r <br />c"NVIRCNMgNTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WCRKSNEET <br />P <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />C <br />L <br />VolfN l Fr�R7�L��E.� <br />�OG/ �TEf/�NSD.r/ <br />S <br />0 <br />I <br />FACILITY ADORESS - <br />SITE PHONE x with AREA CODE <br />R <br />E <br />TEMPORARY CLOSURE FEE - S150.00 each TANK <br />209 <br />T <br />Y <br />CITY T, / <br />ST T <br />ZIP CODE <br />!)"�� <br />of TANKS <br />2 <br />J l V/V <br />at SITE <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />1 <br />MAILING ADDRESS <br />APPLICANT PHONE d WITH -AREA CODE <br />C <br />l gV �� <br />4 <br />N <br />CITY STATE ZIP CODE <br />TYPE of APPLICATION r�"" �Q -61 <br />T <br />y <br />/AtvO�O S7 <br />CLOSURE, INSTALLATION, etc. <br />TOTAL <br />A <br />C <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />T <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />S <br />I <br />V <br />E <br />TANK FEE • 550.00/TANK (prior to January 1,1991) <br />5170/TANK (after January 1, 1991) <br />F <br />Y Tanks = '� <br />1986 <br />1987 <br />1988 1989 1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />A <br />(multiply 9 by fee for <br />C <br />each year applicable) <br />S 3 <br />L <br />STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br />1 <br />T <br />9 Tanks, x 556.00 <br />1986 through 1990 <br />1991 through 1996 <br />Y <br />(enter amount and year) <br />5 112 <br />P <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK 1.0. CS) <br />C <br />L <br />CLOSURE FEE - S53.00 per hour (3 hours minimum per TANK) <br />I TANK(s)_ X 5159.00 • <br />S <br />0 <br />S <br />U <br />TEMPCRARY CLOSURE (A one-time permit, for review 8 inspections <br />TANK I.D. f(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE - S150.00 each TANK <br />+; TANK(s) _ X 5150.00 = <br />S <br />P <br />PLAN CHECK (Install. Plan Review b Construction Inspections) <br />TANK I.D. S(s) <br />E <br />P <br />TANK REPAIR FEE = S53.00 per hour 0 hours minimum/TANK) <br />TANK(s) X 5159.00 <br />L <br />A <br />A2�N <br />PLAN CHECK FEE - $53.00 per hour (8 hours minimum per facility) = $424.00 minimum <br />S <br />R <br />REPAIR <br />TANK I.D. #(s) <br />E <br />P <br />TANK REPAIR FEE = S53.00 per hour 0 hours minimum/TANK) <br />TANK(s) X 5159.00 <br />5 <br />A <br />I <br />R <br />PIPING REPAIR REVIEW 3 CONSTRUCTION = S53.00 per hour (3 hour minimum per facility a 5159.00) S <br />N CONSULTATIONS <br />_ <br />UNAUTHCRIZED RELEASE EVALUATION <br />I SAMPLING INSPECTION <br />1 <br />C FEE = 553.00/hr <br />IFEE - S53.00/hr <br />I FEE = S 53.00/hr <br />nFFlr9 1159 ONLY <br />TOTAL DUE I S <br />